Flexion and Extension

Combined segmental flexion and extension in the lumbar spine averages 15 degrees per segment, with motion increasing in an S-I direction.^5,39 Lumbar flexion and extension combines sagittal plane rotation with an average of 2 to 3 mm of sagittal plane translation in each direction.^5,40,41 White and Panjabi⁵ have proposed that 4.5 mm be considered the upper limit for the radiographic investigation of clinical joint instability. Coupling of lateral flexion and rotation with flexion and extension have also been noted,^28,41 but are considered by White and Panjabi⁵ to be abnormal patterns suggestive of suboptimal muscle control.

The precise location of the IAR for lumbar movements has not been established.⁵ The IAR for flexion and extension is most commonly placed within the IVD of the subjacent vertebrae, with flexion located toward the anterior portion and extension toward the posterior (Figure 5-208). During flexion the vertebra tilts and slides anteriorly as the inferior facets move superiorly and away from the lower vertebra. The disc is compressed anteriorly and stretched posteriorly. During extension the facets approximate one another, and the ALL, anterior portion of the joint capsule, and anterior portion of the disc are stretched (Figure 5-209).

Figure 5-208 Approximate locations for the instantaneous axes of rotation for the 6 degrees of freedom in the lumbar segments.

(From White AA, Panjabi MM: Clinical biomechanics of the spine, ed 2, Philadelphia, 1990, JB Lippincott.)

Figure 5-209 Flexion and extension movements of a lumbar segment.

Lateral Flexion

Segmental lateral flexion averages approximately 6 degrees to each side. Movement is about the same for each segment, with the exception of the lumbosacral joint, which demonstrates approximately half the movement.^5,39 Lateral flexion in the lumbar spine is coupled with opposite-side rotation (e.g., body rotation to the convexity and spinous deviation to the concavity). This leads to a pattern in which the spinous processes end up pointing in the same direction as the lateral flexion (Figure 5-210).^5,42 This pattern is opposite to that in the cervical and upper thoracic spine (see Figures 5-116 and 5-117).

Figure 5-210 Coupling pattern of lateral flexion with contralateral rotation in the lumbar spine.

There are several theoretic factors producing coupled rotation during lateral flexion. One important factor is the principle that it is not possible to bend a curved rod without producing some rotation. The second force acting on the spine to produce coupled rotation is a product of eccentric muscle activity. Lateral bending is controlled mainly by eccentric activity of the quadratus lumborum, which inserts posteriorly to the normal axis of motion. The normal axis is located in the posterior one third of the disc. Therefore, normal muscular activity leads to posterior rotation of the vertebral bodies on the side of convexity and rotation of the spinous processes to the side of concavity.

The IAR for lateral flexion is placed within the subadjacent disc space.⁵ For left lateral flexion, the axis is located on the right side, and for right lateral flexion, on the left (see Figure 5-208). During lateral flexion, the vertebra tilts and slides toward the concave side, producing a smooth, continuous arc. The facets approximate on the concave side and separate on the convex side. The disc is compressed on the concave side and stretched on the convex side. The ligamentum flavum, intertransverse ligament, and capsular ligaments are stretched on the convex side.

Grice⁴³ and Cassidy⁴⁴ have studied the coupling movements for lateral flexion and have proposed classifying segmental lateral flexion into one of four commonly encountered patterns (Figure 5-211). In addition, various pathomechanical theories have been proposed as possible explanations for each abnormal pattern.

Figure 5-211 A, Type I movement of coupled lateral flexion with contralateral rotation under the control of the quadratus lumborum muscle. B, Type II movement of coupled lateral flexion with ipsilateral rotation under the control of the sacrospinalis and multifidus muscles. This pattern may be sectional, as shown here, or segmental. C, Type III movement, consisting of segmental aberrant lateral flexion because of faulty disc mechanics or quadratus lumborum and intertransversalis muscles. D, Type IV movement, consisting of segmental aberrant lateral flexion and rotation because of faulty disc mechanics or psoas and multifidus muscles.

The first pattern, type I movement, exhibits the normal pattern of coupling in which lateral flexion is associated with axial rotation to the opposite side. This produces a pattern in which posterior body rotation occurs on the side opposite the lateral flexion and in which the spinous processes rotate toward the side of lateral flexion. Purportedly, this pattern is represented when normal motor control is exerted through eccentric unilateral contraction of the quadratus lumborum muscle, although synergistic muscles act as a brake to prevent hypermobility. Type I movement may still be abnormal if it is diminished or excessive (see Figure 5-211, A).

Type II motion combines lateral flexion and axial rotation to the same side. This induces posterior body rotation on the side of lateral flexion and rotation of the spinous process to the side opposite the lateral flexion. A muscular imbalance of the sacrospinalis, especially the longissimus and spinalis portions, is proposed as the source of this abnormal pattern. The semislumped sitting posture may also produce this pattern of movement (see Figure 5-211, B).

Type III movement is represented by aberrant segmental lateral flexion and normal coupled rotation. With type III movement, the involved segment demonstrates no lateral flexion or lateral flexion movement in the direction opposite the bending of the trunk. This pattern is theorized to result from faulty disc mechanics or overdominance of the quadratus lumborum or intertransversalis muscles (see Figure 5-211, C).

The last pattern, type IV, is represented by aberrant segmental rotation and lateral flexion. This pattern may also result from faulty disc mechanics or an imbalance in the psoas or multifidus muscles (see Figure 5-211, D).

These patterns are primarily determined by evaluation of lateral bending functional x-ray studies. The use of lateral flexion and flexion-extension movement radiographs has been described (see Figure 3-23) and recommended for evaluation of segmental motion and instability.43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 Although functional radiology should be considered an important potential tool in the evaluation of joint dysfunction, its limitations should also be realized. There is evidence to suggest that findings on lateral bending radiographs do not correlate well with back pain and other abnormal clinical findings.^53,62

Rotation

Axial rotation is quite limited in the lumbar spine. Segmental ROM is uniform throughout the lumbar segments and averages only 2 degrees per motion segment.^5,39 The sagittally oriented facet joints act as a significant barrier to rotational mobility. During rotation, the facet joints glide apart on the side of rotation and approximate on the side opposite rotation (see Figure 5-202). The instantaneous axis for axial rotation is placed within the posterior nucleus and annulus¹ (see Figure 5-208).

Rotation of the lumbar spine is also consistently coupled with lateral flexion and slight sagittal plane rotation. The coupled lateral flexion varies between upper and lower lumbar segments. Rotation in the upper three segments (L1–L3) is coupled with opposite-side lateral flexion. Rotation in the lower two segments (L4 and S1) is coupled with same-side lateral flexion.^28,63 The transitional change in coupling that occurs at the L4–5 motion segment may be of clinical significance in predisposing this level to increased torsional stress, clinical instability, and degenerative change.⁵

The pattern of coupled sagittal plane rotation depends on the starting position of the lumbar spine.²⁸ With the spine in a neutral starting position, the lumbar spine flexes at all levels when rotated. When the spine is rotated from a flexed posture, it has a tendency to extend, and when rotated from an extended posture, it has a tendency to flex. This pattern was also noted for lateral flexion, leading to the generalization that “lateral bending or axial rotation has a tendency to straighten the spine (move it toward a neutral posture) from the flexed as well as the extended postures.”⁵

Observation

The assessment of lumbar function should begin with an evaluation of lumbopelvic alignment and ROM. The sacral base forms the foundation of the spine, and a functional or structural alteration in the pelvis or lower extremities may alter the alignment of the lumbar spine and segments above. Pelvic and hip alignment are evaluated by observing the alignment of the gluteal folds, posterior iliac spines (sacral dimples), and iliac crests.

To palpate the alignment of the pelvis, place the thumbs on the posterior iliac spines and the fingertips along the superior margin of the crests (Figure 5-213). Compare each side for symmetry and their orientation to the greater trochanter for possible leg length inequality.

Figure 5-213 Observation of lumbopelvic alignment and posture with palpation of the posterior iliac spines and iliac crests.

Coronal plane alignment of the lumbar spine is evaluated by observing the orientation of the spinous process, status of the paraspinal muscles, and contours of the waist (Figure 5-214). Scoliotic curvatures in the lumbar spine are frequently represented by muscle asymmetry and increased paraspinal muscle mass on the convex side of scoliosis. Compensatory curvatures are common in the lumbar spine, and any noted deviations should be followed up with an assessment of leg length.

Figure 5-214 Posterior plumb line observation, demonstrating pelvic unleveling low on the right, with a right convex curve in the lumbar spine.

Sagittal plane orientation of the hips, pelvis, and lumbar spine is evaluated from the side. The lumbosacral angle in large part determines the angle of the lumbar curve and is often mirrored by the positioning of the pelvis. Anterior or posterior tilting of the pelvis usually results from alterations in the hip angle. Anterior pelvic tilt results from bilateral hip flexion, and posterior pelvic tilt results from bilateral hip extension (Figure 5-215).

Figure 5-215 Observation of posture from a lateral view, showing an anterior pelvic tilt with lumbar hyperlordosis (A) and a posterior pelvic tilt with lumbar hypolordosis (B).

Anterior pelvic tilt increases the lumbosacral angle and lumbar curve; posterior pelvic tilt reduces the lumbosacral angle and curve. The lumbar curve also alters its angle relative to structural alteration in the thoracic curve. Congenitally straight thoracic curves often lead to straightening of the lumbar and cervical curves. Increased thoracic kyphosis may lead to accentuation of the lumbar and cervical curves.

Lumbopelvic movement should be observed for range and symmetry. Flexion, extension, and lateral flexion are usually assessed with the patient standing. Rotation is more effectively evaluated in the sitting position to fix the pelvis and prevent hip rotation.

To assess flexion, the patient bends forward, and any limitations, painful arcs, or alterations in normal sequencing are observed. With normal range, the patient should be able to come within several inches of the floor with the fingertips, and the lumbar curve should reverse (Figure 5-216).

Figure 5-216 Observation of thoracolumbar range of motion. A, Flexion. B, Extension. C, Lateral flexion. D, Rotation.

After the patient returns to neutral, the doctor should stabilize the patient’s hips while extension is performed. Extension is significantly more limited than flexion, and mild midline lumbosacral discomfort is commonly associated with full extension.

Lateral bending is evaluated by instructing patients to bend to one side while running their fingers down the lateral surface of the leg. It is important to ensure that the patient does not axially rotate the trunk, bend the knee, or raise the foot off the floor while bending. The movement should be symmetric, and the doctor should record where the patient’s fingertips pass relative to the knees. A smooth C curve should be observed to the side of bending. Areas of regional restriction or increased movement may be noted by observing for a sudden break (bent-stick configuration) in integrated movement.

To isolate movements of the lumbar spine from hip and thoracic movements, the doctor may use inclinometric methods and measure movement between the thoracolumbar and lumbosacral regions. Table 5-8 lists the normal ranges for lumbar movement; the methods for measuring movement have been previously described (see Figure 3-10).

TABLE 5-8 Global ROMs for the Lumbar Spine

Static Palpation

To evaluate the bony and soft tissue structures of the lumbar spine, the patient is placed in the prone position and scanned for areas of potential tenderness, misalignment, or asymmetry.

To scan the bony landmarks, use the pads of the fingers or thumbs and palpate the spinous processes, interspinous spaces, and mammillary processes (Figure 5-217). Palpation of the interspinous spaces is enhanced by placing a small roll under the abdomen or elevating the lumbar and pelvic sections of an articulating table. The mammillary processes are not distinctly palpable; rather, the doctor feels for a sense of firmness in the soft tissue as the contact passes over each mammillary process. Rotational prominence of lumbar spinal segments is perceived by a sense of fullness in the muscles over the top of the mammillary processes and not by actual palpation of bony rotation.

Figure 5-217 Palpation of lumbar interspinous alignment and sensitivity (A) and paraspinal muscle tone, texture, and sensitivity (B).

Palpation of the lumbar paraspinal soft tissues is conducted by applying bilateral contacts with the palmar surfaces of the fingers or thumbs. Evaluation should incorporate an assessment of tone and texture of the erector spinae, quadratus lumborum, deep segmental muscles, and iliolumbar ligaments. The psoas muscle should also be palpated for tone and tenderness. The psoas is accessible for palpation in the supine position, and the belly becomes more evident by inducing hip flexion on the side of palpation.

Motion Palpation

Joint Play

The lumbar spine may be scanned in the sitting or prone position for sites of painful or restricted JP. Sites of suspected abnormality should be further assessed with specific JP tests. The same methods applied in the thoracic spine for assessing P-A glide and counter-rotation may be applied to the lumbar spine (Figure 5-218). Additional options include the evaluation of rotation, the assessment of lateral glide, and a side-posture method for evaluating possible instability.

Figure 5-218 Lumbar joint play evaluation for posterior-to-anterior glide. A, Bilateral thenar contacts over the mammillary processes. B, Digit contact over the spinous process.

To assess rotational JP, the doctor contacts adjacent spinous processes (Figure 5-219) or the spinous process and the anterior crest of the ilium and applies counter-rotation across the joint. Normal movement is pain-free and is associated with a sense of giving with pressure and recoil when pressure is released.

Figure 5-219 Counter-rotational joint play evaluation for left rotational movement of L3 relative to L4. Opposing forces are directed toward the midline through a contact established on the left side of the L3 spinous process and the right side of the L4 spinous process.

Lateral glide of individual lumbar motion segments may be evaluated with the patient in the prone position by establishing a thumb contact against the lateral surface of adjacent spinous processes with the cephalic hand while the other hand grasps the patient’s anterior and medial thigh (Figure 5-220). Movement is induced by applying medial pressure against the spinous process while the patient’s leg is passively abducted. Normal movement is represented by segmental bending and shifting of the spinous process away from the contact. This procedure can also be performed by moving the pelvic section of a flexion table from side to side.

Figure 5-220 Lumbar joint play evaluation for lateral glide in the L3–4 motion segment, using a thumb contact across the left L3–4 interspinous space.

To evaluate segmental stability in side posture, place the patient on either side, with the upper thigh and knee flexed. Establish a fingertip contact over the spinous processes and interspinous spaces with the cephalic hand and straddle the patient’s flexed knee (Figure 5-221). Apply posterior shearing pressure through the patient’s knee and gentle anterior pressure through the palpation hand. Feel for gliding between adjacent spinous processes. Excessive posterior glide (translation) of the inferior spinous process relative to the superior spinous process suggests possible clinical joint instability.

Figure 5-221 Side-posture evaluation for lumbar clinical instability, with the doctor applying an anterior-to-posterior force along the line of the shaft of the patient’s femur while palpating for increased translational movement between L3 and L4.

Lumbar Segmental Motion Palpation and End Play

Lumbar segmental motion may be evaluated with the patient in the sitting or side-posture positions. Both postures are effective for assessing lumbar mobility, but side-posture positions do not provide as much freedom for full trunk movement. This is especially true for the evaluation of lumbar lateral flexion and end play.

Sitting Methods

For sitting evaluations, place the patient on an adjusting bench or palpation stool with the arms crossed over the chest. The doctor may sit behind or stand beside the patient. Movement is controlled through contacts on the patient’s shoulders.

Rotation

Lumbar segmental rotation is evaluated by establishing a thumb contact against the lateral surface of adjacent spinous processes. The contact is placed on the side of induced rotation so that the pad spans the interspinous space. The support hand reaches around the front of the patient, hooks the patient’s anterior shoulder or grasps the opposite forearm, and rotates the patient’s trunk toward the side of contact (Figure 5-222). During normal rotation the doctor should palpate the superior spinous process, rotating away from the spinous process below. Movement should occur in the direction of trunk rotation. If separation is not noted and adjacent spinous processes move together, segmental restriction should be suspected.

Lumbar segmental movement is quite limited in rotation (1 to 2 degrees), and the examiner may not be able to discriminate reductions of movement within these limits. Therefore, the doctor should concentrate on movement of the segment from its neutral position (any shifting between adjacent spinous processes) and on the quality of end-play movement.

Although the lumbar facets do provide a bony obstacle to rotation, there is still some normal give to rotational end play. To assess end play, the doctor applies additional overpressure at the end of passive motion. Contacts may be established against the superior spinous process on the side of induced rotation (Figure 5-222) or over the mammillary process and posterior joint on the side opposite the induced rotation.

Figure 5-222 Segmental ROM and end-feel evaluation for left rotation at the L2–3 articulation, using a thumb contact across the left L2–3 interspace.

Lateral Flexion

To assess lateral flexion, the palpation contact is also established against the lateral surface of adjacent spinous processes. The contact is placed on the side of desired lateral flexion and the patient is asked to bend toward the side of contact (Figure 5-223). The doctor guides movement by applying downward and medial pressure through the shoulder contact and medial pressure through the contact hand. The indifferent arm and contact arm must work together to maximize bending at the site of palpation. To induce lateral flexion in the lumbar spine, the patient’s upper trunk must be shifted sufficiently to the side of bending. During the performance of lateral flexion, the doctor should feel the spine bend smoothly around the contact and the spinous process shift toward the opposite side (convex side).

Figure 5-223 End-feel evaluation for right lateral flexion at the L2–3 motion segment, using a thumb contact across the right lateral aspect of the L2–3 interspace.

End-play evaluation is conducted by shifting the contact to the superior spinous process and applying additional overpressure at the end ROM. Lateral flexion end play is more elastic than rotation; a firm but giving response should be noted.

Flexion and Extension

Lumbar flexion and extension are evaluated by establishing palpation contacts in the interspinous spaces with the doctor’s fingertips or dorsal middle phalanx of the index finger (Figure 5-224). Movement is induced by asking the patient to slouch and arch the lumbar spine. The indifferent arm and palpation hand help guide movement and ensure that the apex of bending is accentuated at the level of palpation. During flexion the interspinous spaces should open, and during extension they should approximate.

Figure 5-224 Movement evaluation of lumbar flexion, with fingertip contacts in the L2–3 and L3–4 interspace.

Flexion end play is assessed by contacting the superior spinous process with the thumb or fingertips while gentle downward pressure is applied through the doctor’s IH and arm against the patient’s shoulders (Figure 5-225, A). To induce extension, push anteriorly against the contact while inducing backward bending (see Figure 5-225, B). Extension end play is inhibited by the impact of the spinous processes and has a more rigid quality than flexion.

Figure 5-225 A, End-play evaluation for flexion at the L2–3 motion segment, using a thumb contact over the inferior tip of the L2 spinous process. B, Lumbar extension end play, with a reinforced interphalangeal joint contact over the L2–3 interspace.

Side-Posture Methods

To conduct side-posture mobility tests, the patient is placed on his or her side, with the down-side arm crossed over the chest and resting on the opposite shoulder. The down-side leg is extended along the length of the table, and the knee and hip of the opposite leg are flexed. The doctor controls movement through the patient’s shoulders and by cradling the patient’s flexed leg.

Flexion and Extension

To evaluate flexion and extension, stand facing the patient and cradle the patient’s flexed knee between your thighs. Palpate the interspinous space with the caudal hand and grasp the patient’s shoulder with the cephalic hand and forearm. Induce flexion and extension by moving the patient’s knees superiorly and inferiorly, and feel for opening and closing of the interspinous spaces (Figure 5-226).

Figure 5-226 A, Side-posture movement evaluation for flexion. B, Extension of the L4–5 motion segment, using a fingertip contact over the L4–5 interspace.

Lateral Flexion

To assess lateral flexion, use the caudal hand to establish a contact on the ischial tuberosity and gluteal soft tissues of the patient’s up-side hip. Place the fingertips or thumb of the doctor’s cephalic hand on either side of adjacent spinous processes and interspinous space. To induce movement, push headward against the patient’s pelvis with the caudal hand while palpating for movement at the interspinous spaces (Figure 5-227). On the concave side of bending, the interspinous spaces should close and open on the convex side. If dysfunction is present, the spinous processes do not move into the doctor’s palpating fingers on the convex side (down side) or remain firm and do not glide away if palpating is done from the concave side (up side).

Figure 5-227 Side-posture movement evaluation for lateral flexion of the L2–3 motion segment, using a thumb contact over the lateral aspect of the L2–3 interspace.

Rotation

Side-posture lumbar rotation may be assessed by inducing movement through the patient’s trunk or pelvis. If the patient’s trunk is used, the indifferent contacts are established against the patient’s up-side shoulder (Figure 5-228). If the pelvis is used, the indifferent contacts are established against the patient’s thigh or proximal leg. The patient’s torso can be contacted with the doctor’s superior hand or forearm (Figure 5-228, A). When counterrotating the shoulder and pelvis, slide your forearm between the patient’s arm and chest, contact the shoulder, and have the patient grasp the opposite forearm with the up-side hand or the shoulder will not provide enough resistance to induce rotation (Figure 5-228, B). To induce movement through the pelvis, contact the patient’s up-side thigh with the dorsal surface of the caudal ankle or distal thigh. For both methods, locate the palpation contacts at the desired interspinous space with the middle finger or thumb of the caudal hand.

Figure 5-228 Side-posture movement evaluation of rotation at the L3–4 motion segment. A, Evaluation of right rotation mobility. Caudal hand establishes fingertip contacts over the L3–4 spinous process while the cephalad hand induces posterior trunk rotation. B, Evaluation of left rotation, using fingertip contacts over the left lateral surface of the L3 spinous process and right lateral surface of the L4 spinous process with counterrotation of shoulders and pelvis.

To induce trunk movement, apply posterior pressure against the patient’s shoulder and forearm. To induce pelvic rotation, apply downward pressure against the patient’s distal thigh or proximal leg (5-228B). When movement is initiated through the trunk, the superior spinous process rotates away from the inferior spinous process in the direction of trunk rotation (toward the table). When movement is initiated with the pelvis, the inferior spinous process rotates away from the superior spinous process in the direction of pelvic rotation (away from the table).

Side-Posture Adjustments

Side-posture lumbar adjustments are the most frequently applied adjustments for lumbar spinal dysfunction. They offer freedom of movement to alter patient position and adaptability to methods that improve the doctor’s leverage and mechanical advantage. Although they are difficult adjustments to perfect, doctors can reduce frustration by understanding their mechanical principles and effects.

The level of segmental tension is regulated by patient positioning and the degree of induced lumbar flexion, lateral flexion, and the amount of counter-rotation induced between the shoulders and pelvis (Figure 5-229). The direction of adjustive thrust in relation to the direction of torso movement and pelvic movement is also important in localizing the adjustive.

Figure 5-229 Side-posture patient positioning. A, Development of segmental flexion and distraction of the posterior joint by flexing the patient’s upper knee and hip. B, Development of lateral flexion by placing a pillow under the lumbar spine and pulling the patient’s shoulder down and forward. C, Counter-rotation of the pelvis and shoulders to induce gapping distraction in the up-side (left) facet joint.

Adjustments that direct the adjustive thrust in the same direction as torso movement but opposite pelvic movement are defined as assisted adjustments. Adjustments that direct the adjustive thrust in a direction opposite the torso movement and in the same direction as pelvic movement are defined as resisted adjustments (Figure 5-230). Assisted adjustments are applied to develop maximal preadjustive tension in the motion segments inferior to the established contact, and resisted adjustments are applied to develop maximal tension in the motion segments superior to the established contact.

Figure 5-230 Side-posture positioning for rotational dysfunction. A, Resisted positioning, with contact applied to the inferior vertebra to induce gapping in the joints superior to the contact. B, Assisted positioning, with contact applied to the superior vertebra to induce gapping in the joints inferior to the contact. Arrows indicate adjustive vectors and direction of shoulder and pelvic rotations.

The degree of torso movement is determined by the positioning of the patient’s shoulders, and the degree of pelvic movement is determined by the placement of the patient’s pelvis. Various methods for positioning and contacting the patient’s shoulders and pelvis are pictured in Figures 5-231, 5-232, and 5-233.

Figure 5-231 Movement of the patient’s lower arm to assist in the development of lateral flexion. A, Lateral flexion away from the table, induced by pulling the arm headward to place the patient on the lateral surface of the shoulder to produce left lateral flexion (LLF). B, Lateral flexion toward the table, induced by pulling the arm footward to place the patient on the posterolateral surface of the shoulder to produce right lateral flexion (RLF). Elevation of the pelvic and lumbar sections or a pillow placed under the lumbar spine will assist in the development of lateral flexion toward the table.

Figure 5-232 Optional patient arm positioning for side-posture adjusting. A, Forward positioning of the upper arm applied with flexible individuals to maintain neutral trunk positioning. B, Midline positioning of the upper arm to accommodate neutral positions or positions incorporating slight posterior trunk rotation. C, Posterior positioning of the upper arm applied with large patients or specifically to induce posterior movement of the trunk.

Figure 5-233 Optional leg contacts that may be used in the application of side-posture pelvic and lumbar adjustments. A, Lateral thigh-to-thigh contact. B, Square stance shin-to-knee contact. C, Straddle thigh contact. D, Straddle flexed-knee contact.

Proper use of body weight and leverage is also critical to the effective application of side-posture adjusting. Side-posture adjustments often demand the added force that is produced by incorporating the doctor’s body weight in the development of preadjustive tension and adjustive thrusts.⁶⁴

Prone and Knee-Chest Adjustments

Prone and knee-chest adjustments are applied with specific short-lever contacts (Figure 5-234). They are especially suited to the treatment of extension restrictions or adjusting situations in which it is desirable to minimize rotation. Extension is easily induced in the prone or knee-chest positions, and the lumbar sagittal facet facings do not conflict with anteriorly directed adjustive VECs. The doctor also has the advantage of centering their body over the contact.

Figure 5-234 Prone unilateral hypothenar mammillary adjustment.

Because the knee-chest positions are especially helpful in maximizing lumbar extension, the patient is vulnerable to hyperextension in this position. Therefore, the doctor must be skilled in the application of this procedure and deliver the adjustive thrust in a shallow and nonrecoiling manner.

Sitting Lumbar Adjustments

Sitting lumbar adjustments (Figure 5-235) conform to the same mechanical principles previously discussed for sitting thoracic adjustments. They use assisted methods and are applied to develop maximal tension in the motion segments below the level of contact. They are typically applied for lumbar rotation or combined rotation and lateral flexion dysfunction. The most frequent and effective site of application occurs at the thoracolumbar region. Critical to their application is an understanding of the thoracolumbar transition to sagittal facet orientation and the effect this has on axial rotation and facet movements.

Figure 5-235 Sitting mammillary push adjustment.

Rotational Adjustments

Rotational dysfunction of the lumbar spine theoretically may result from decreased mobility in the posterior joints on the side of rotational restriction or on the side opposite rotational restriction. Although the movements on each side are small, reduced play in either joint is potentially detrimental to joint function. Fixation in the joint on the side of rotational restriction may produce a loss of facetal separation (Figure 5-236). Fixation in the joint on the side opposite the rotational restriction (compression facets) may theoretically produce a loss of anterior glide of the inferior facet relative to the superior facet (see Figure 5-236). The facet joints on the side opposite the direction of trunk rotation act as a major barrier to axial rotation. Bony impact of these structures is largely responsible for limiting lumbar rotation. As a result, functional changes in the periarticular soft tissues of these joints are unlikely to significantly affect the range of axial rotation. In contrast, the joints on the side of trunk rotation are not limited by bony impact. Therefore, functional changes in these articulations may have a significantly greater potential to limit joint movement.

Figure 5-236 Illustration of right rotation, demonstrating gapping of the right articulation and anterior glide and approximation of the left articulation.

Rotational dysfunction leading to a loss of gapping on the side of restricted rotation may be treated with side-posture assisted or resisted methods. With both patient positions, the affected joint is placed up (away from the table) and the patient is flexed, laterally flexed toward the table, and counter-rotated at the level of dysfunction.

With resisted methods, the contact is established on the up-side mammillary process or the down-side of the spinous process of the inferior vertebra. The thrust is delivered in the direction opposite the shoulder rotation. This method is applied to induce rotation and gapping in the facet joints superior to the point of contact (Figure 5-237).

Figure 5-237 Resisted position with a hypothenar contact applied to the right L4 mammillary process to induce right rotation and gapping of the right L3–4 articulation.

With assisted methods, the contact is established on the spinous process of the superior vertebra and the thrust is delivered in the direction of shoulder rotation. This method is also applied to induce facet gapping, but the point of distraction is directed to the articulations below the contact (Figure 5-238). To incorporate forces applied in each of the previous two methods, apply a combination spinous push-pull adjustment (Figure 5-239).

Figure 5-238 Assisted position, with a hypothenar contact applied to the right L3 spinous process to induce right rotation and gapping of the right L3–4 articulation.

Figure 5-239 Digital contacts applied to the right lateral surface of the L3 spinous process and left lateral surface of the L4 spinous process to induce right rotation and gapping of the right L3–4 articulation.

To induce rotation and facet gapping in the sitting position, use patient postures that are identical to those used with side-posture assisted spinous push adjustments. Contact the lateral surface of the superior spinous process on the side of rotational restriction (side of spinous rotation) or over the mammillary process on the side opposite the rotational restriction. Laterally flex the patient away from the side of desired facet gapping and rotate the torso in the direction of restriction (Figure 5-240).

Figure 5-240 Assisted method, with a hypothenar contact applied to the right lateral surface of the L3 spinous process to induce right rotation and gapping of the right L3–4 articulation.

Rotational restrictions may also be treated with assisted side-posture mammillary push adjustments or assisted sitting mammillary push adjustments. The contacts are applied to the superior vertebra of the involved motion segment on the side of posterior body rotation (side opposite the rotational restriction). These methods are directed at distracting the motion segment inferior to the point of contact. These procedures establish a contact on the side of facet approximation contralateral to the side of facet gapping. Therefore, they may be less effective at inducing joint gapping then the previous methods described, which establish contacts on the same side of the desired joint gapping.

In the side-posture method, take care to maintain the patient’s relatively neutral shoulder position. Excessive posterior shoulder rotation opposes the direction of adjustive thrust and may place unwanted distractive tension at the joint above the desired level. In addition, consider incorporating a superior inclination to the adjustive thrust (Figure 5-241). This serves to direct the thrust along the plane of the lumbar sagittal facets and may minimize compression of the facet joints.

Figure 5-241 Assisted method, with a hypothenar contact applied to the right L3 mammillary process (dot) to induce left rotation.

When using a sitting mammillary push adjustment, some lateral flexion of the patient away from the side of contact may assist in distraction the affected joint (Figure 5-242). If the patient is laterally flexed toward the side of contact and the adjustive thrust is directed anteriorly without superior distraction, there is a risk of unnecessary compression of the joint.

Figure 5-242 Assisted method, with a hypothenar contact applied to the left L3 mammillary (dot) to induce right rotation or right lateral flexion.

Lateral Flexion Adjustments

Lateral flexion dysfunction in the lumbar spine may result from a loss of disc closure and approximation of the facet joints on the side of lateral flexion dysfunction or contralateral loss of distraction of the facet and soft tissues on the side opposite the lateral flexion restriction (Figure 5-243).

Figure 5-243 Illustration of right lateral flexion, demonstrating the right facet joints gliding together and the left facet joints gliding apart.

Lateral flexion dysfunction is commonly treated with side-posture adjustments, but may also be treated in sitting positions. In side-posture positions, the adjustive contacts are established on the spinous process or the mammillary processes. Assisted patient positions are used with spinous process contacts with pillows or positioning of the lumbar and pelvic sections to enhance the lateral flexion position. The patient is placed on the side opposite the lateral flexion restriction and the patient is laterally flexed away from the table (laterally flexed toward the doctor) (Figure 5-244). After tension is developed, the doctor thrusts posteriorly to anteriorly and laterally to medially to induce segmental lateral flexion and closure of the up-side facet joint and disc and separation of the down-side facets and disc.

Figure 5-244 Assisted method, with a hypothenar contact applied to the right lateral surface of the L3 spinous process (dot) to induce right lateral flexion of the L3–4 motion segment.

When using mammillary contacts, the patient is placed with the side of lateral flexion restriction down. The patient is laterally flexed toward the table to distract the up-side joint. A roll may be placed under the patient to assist in the development of distraction. The contacts are established on either the upper or lower vertebra. With a contact on the superior vertebra, the thrust is delivered anteriorly and superiorly in the direction of trunk bending to distract the joints below the contact (Figure 5-245). With an inferior vertebra contact, the thrust is directed anteriorly and inferiorly to distract the joints above the contact. Upper vertebra contacts are much more commonly applied and easier on the doctor’s wrist and shoulder.

Figure 5-245 Assisted method, with a hypothenar contact applied to the right L4 mammillary process (dot) to induce left lateral flexion of the right L4–5 motion segment.

When mammillary contacts are applied to accentuate disc closure, the patient is placed with the side of lateral flexion restriction up. The patient is laterally flexed away from the table, and the doctor thrusts posteriorly to anteriorly, laterally to medially, and superiorly to inferiorly to induce approximation of the facets and disc closure (Figure 5-246). This procedure is not commonly used unless lateral flexion restrictions are also coupled with opposite-side rotation restrictions (posterior right inferior [PRI] or posterior left inferior [PLI listings].

Figure 5-246 Assisted method, with a hypothenar contact applied to the right L3 mammillary (dot) to induce right lateral flexion of the L3-4 motion segment.

It is unlikely that adjustive VECs directed up or down the spine in a patient positioned in a neutral position will induce lateral flexion.³² The production of lateral flexion is more likely if the patient is prestressed and allowed to move in the direction of lateral flexion restriction (Figure 5-246). The use of rolls, wedges, and articulating tables can assist in this capacity.

Flexion and Extension Adjustments

Flexion dysfunction is commonly treated in the side-posture position, with contacts established over the spinous processes. The spine is flexed at the level of dysfunction, and contacts are applied to the superior or inferior vertebra of the involved motion segment to induce separation of the interspinous space and posterior joints. With assisted methods, the contact is established on the superior vertebra, and the thrust is directed anteriorly and superiorly (Figure 5-247). With resisted methods, the contact is applied to the inferior vertebra and the thrust is directed anterior and inferiorly. Resisted methods are not commonly applied, except at the lumbosacral junction, where the contacts are established on the sacral apex.

Figure 5-247 Assisted method, with hypothenar contact applied over the L5 spinous process to induce distraction in the L5–S1 motion segment.

Extension dysfunction is also treated in side-posture position with spinous contacts. In this case, the involved motion segment is allowed to extend, and the doctor establishes contacts over the superior or inferior spinous process and directs the adjustive thrust to induce approximation of the posterior joints and disc and distraction of the anterior elements (Figure 5-248). The resisted method may be the procedure of choice because of the associated slight I-S VEC that minimizes stress to the doctor’s shoulder.

Figure 5-248 Resisted method, with a hypothenar contact applied to the L5 spinous process (dot) to induce extension in the L4–5 motion segment.

It is unlikely that adjustive VECs directed up or down the spine in a patient positioned in a neutral position will induce flexion or extension.³² The production of flexion or extension is more likely if the patient is prestressed and allowed to move in the direction of restriction.

As mentioned previously, prone or knee-chest adjustments may be especially efficient in the delivery of lumbar extension adjustments. They are applied with unilateral or bilateral contacts, depending on whether you wish to induce extension with or without coupled rotation. The contacts may be established over the spinous processes but are more commonly applied over the mammillary processes.

Side Posture

Resisted method: To effect rotation with a resisted method, place the patient on the side opposite the rotational restriction and contact the mammillary of the inferior vertebra on the side of rotational restriction. For example, when treating an L3–4 right rotation restriction (L3 left posterior body rotation), place the patient on the left side and establish a contact over the right L4 mammillary (see Figure 5-249, B).

Figure 5-249 A, Assisted method, with a hypothenar contact applied to the right L4 mammillary process to induce left rotation at the right L4–5 motion segment. B, Resisted method, with a hypothenar contact applied to the right L4 mammillary process to induce right rotation and gapping of the right L3–4 articulation. C, Assisted method, with a hypothenar contact applied to the right L4 mammillary process to induce right lateral flexion of the left L4–5 motion segment. D, Resisted method, with a hypothenar contact applied to the right sacral base to induce right lateral flexion in the L5–S1 motion segment. E, Assisted method, with a hypothenar contact applied to the right L3 mammillary process to induce left lateral flexion in the L3–4 motion segment.

To develop preadjustive tension, rotate the patient’s shoulders posteriorly, laterally flex the trunk toward the adjusting bench, and counter-rotate the patient’s pelvis anteriorly. This should induce gapping distraction in the motion segment ipsilateral superior to the point of contact.

Shoulder rotation and lateral flexion are induced by pulling the patient’s down-side arm anteriorly and inferiorly (see Figure 5-231, B and C). Lateral flexion of the patient may be assisted by elevating the thoracolumbar section of an articulating adjustive bench or by placing a roll under the patient’s lumbar spine. Forward rotation of the patient’s pelvis is aided by downward traction along the patient’s flexed thigh and hip by the doctor’s anterolateral thigh (see Figure 5-223, A) or lower abdomen (see Figure 5-233, C and D).

The degree of shoulder rotation depends on the area being treated. It is greater in the upper lumbar spine as compared with the lower lumbar spine. Excessive counter-rotation through the shoulders may be unnecessarily uncomfortable to the patient and may be stressful to his or her intercostal muscles.

At tension, deliver an impulse thrust through the body and contact arm. The adjustive VEC follows the movement of the pelvis and should not be directed straight anteriorly. Thrusts directed anteriorly have a tendency to induce segmental extension instead of rotation and joint gapping. The contact must remain light, and the VEC must reinforce the pelvic rotation by incorporating a strong M-L component (see Figure 5-249, B).

Resisted adjustive methods may also be used to treat rotational restriction coupled with opposite-side lateral flexion restrictions ([PRI], [PLI], left posterior superior [LPS], right posterior superior [RPS] listings).

Rotation restrictions: To effect rotation, place the patient on the side opposite the rotation restriction (side opposite spinous rotation). Rotate the shoulder posteriorly in the direction of restriction and laterally flex the trunk toward the adjusting bench. Induce shoulder rotation and lateral flexion by pulling the patient’s down-side arm anteroinferiorly (see Figure 5-250, A). Establish the segmental contact and remove superficial tissue slack by sliding medially onto the lateral surface of the superior spinous process (side of spinous rotation). The contact must remain light and well padded or it becomes painful.

Figure 5-250 A, Assisted method, with a hypothenar contact applied to the right lateral surface of the L3 spinous process to induce right rotation in L3- motion segment. B, Assisted method, with a hypothenar contact applied to the right lateral surface of the L3 spinous process to induce right lateral flexion in the L3–4 motion segment. C, Resisted method, with a hypothenar contact applied to the sacral apex to induce flexion in the L5–S1 motion segment. D, Resisted method, with a hypothenar contact applied to the spinous process of L5 to induce extension in the L4–5 motion segment. E, Assisted spinous push adjustment, with contact established over the right lamina of the L4 spinous process to induce L4–5 right rotation and right lateral flexion.

Develop preadjustive tension by rotating the patient’s shoulder and contacted vertebra posteriorly while the patient’s pelvis and the segments below are rotated anteriorly. The forward rotation of the patient’s pelvis is aided by downward traction along the patient’s flexed thigh and hip by your anterolateral thigh. At tension, deliver an impulse thrust through the body and contact arm.

P: Ask the patient to lie on the appropriate side and to straighten the down-side leg. Flex the patient’s upper thigh to distract the interspinous space of the dysfunctional motion segment. Then establish contacts on the spinous process, lateral hip and the patient’s flexed leg. The spinous contacts are established by hooking the down side of the spinous process with the second, third, and fourth fingers while the forearm rests against the patient’s posterolateral buttock and hip.

Figure 5-251 A, Assisted method, illustrating a digital contact applied to the left lateral surface of the L4 spinous process to induce left rotation in the L4–5 motion segment. B, Resisted method, illustrating a digital contact applied to the left lateral surface of the L5 spinous process to induce right rotation in the L4–5 motion segment and gapping of the right L4–5 articulation.

When using a square stance, contacts on the patient’s leg are established with the doctor’s knee or distal shin (Figure 5-251, A). When using a fencer stance, the contacts are established on the patient’s leg with the doctor’s mid-thigh (Figure 5-251, B).

At tension, a pulling impulse is generated by extending your contact shoulder while simultaneously inducing anterior pelvic rotation by accelerating through the patient’s leg contact. To generate anterior pelvic rotation with a square stance and distal shin–to–patient knee contact, quickly extend the contact knee (Figure 5-251, A). With a knee-to-knee contact, extend your hip and drop your body weight through the patient’s knee and forearm contact on the patient’s lateral hip. With a fencer stance and thigh–to–patient’s shin contact, generate rotation by accelerating your body weight through the contacts on the patient’s lateral hip and shin (Figure 5-251, B). The digit contacts on the spinous are primarily used for sensing preadjustive tension. The primary adjustive force is generated through the leveraged contacts established on the patient’s lateral thigh and lower extremity.

P: Place the patient in side posture. Flex the patient’s upper thigh to distract the interspinous space of the dysfunctional motion segment. Rotate the patient’s shoulder posteriorly in the direction of segmental restriction and flex the trunk laterally toward the adjusting bench.

Figure 5-252 Digital contacts applied to the right lateral surface of the L2 spinous process and left lateral surface of the L3 spinous process to induce right rotation and gapping of the right L2–3 articulation. A, Illustrates contact between the doctor’s thigh and patient’s leg. B, Illustrates contact between the patient’s knee and the doctor’s knee.

The doctor establishes appropriate contacts on the adjacent spinous process and develops local joint tension by counter-rotating the pelvis, shoulders, and segmental contacts. As the shoulders are rotated posteriorly, the patient’s pelvis and contacted vertebra are counter-rotated anteriorly. This should induce distraction in the motion segment between the established contacts. Posterior shoulder rotation is greater when treating upper lumbar dysfunction as compared with lower lumbar dysfunction.

At tension, deliver a high-velocity countertorquing thrust through both contact arms, reinforced by a shallow thrust through the contacts established on the patient’s shoulder, leg, or shin. Take care not to apply undue pressure to the patient’s lateral rib cage with the superior forearm contact. (The digit contacts on the spinous are primarily used for sensing preadjustive tension. The primary adjustive force is generated through the leveraged contacts established on the patient’s lateral thigh, proximal shoulder and lower extremity.)

Prone

Figure 5-253 Bilateral thenar contacts applied to the mammillary processes of L3 to induce extension at the L3–4 motion segment.

P: The patient lies prone, with the thoracic section released and lowered to assist in the development of segmental extension. Remove superficial tissue slack and establish adjustive contact. Develop preadjustive tension by transferring additional body weight into the contact. Deliver an impulse thrust through the arms, trunk, and body. The thrust may be applied with a lumbar drop section.

Figure 5-254 A, Hypothenar contact applied to the right L1 mammillary process to induce extension and left rotation at the L1–2 motion segment. B, Hypothenar contact applied to the right L1 mammillary process, with countertraction applied through the anterior pelvis to induce left rotation at the right L1–2 motion segment.

The contact may be reinforced with the IH, or the IH may contact the ipsilateral anterior ilium. When applying a reinforcing contact, stand on the side of adjustive contact (see Figure 5-254, A). If the IH contacts the ilium, stand on the side opposite the adjustive contact (see Figure 5-254, B).

When using an ilial contact, develop preadjustive tension by lifting and tractioning inferiorly against the ilium as the weight of your trunk is transferred anteriorly and superiorly against the contact. The counterdistractive tension through the ilium should be limited, and the patient’s pelvis should not be rotated off the table more than 1 to 2 inches. Deliver the thrust with an impulse and body-drop thrust through the contact hand. It is unlikely that lateral flexion can be effectively induced in prone neutral positions. Prestressing the patient into lateral flexion and inducing lateral flexion during the delivery of the adjustment may assist in the production of lateral flexion.

P: The patient lies prone, with the thoracolumbar section of the table released and lowered to assist in the development of segmental extension. Establish a fleshy hypothenar contact against the spinous process on the side of rotation restriction (side of spinous rotation). The contact is developed by sliding medially onto the spinous process while inducing a slight clockwise or counterclockwise torquing movement, depending on the side of contact. The torquing movement is applied to assist in the development of a firm contact.

Figure 5-255 Hypothenar contact applied to the left L2 spinous process to induce extension, left lateral flexion, and left rotation of the L2–3 motion segment.

Develop preadjustive tension by transferring additional body weight into the contacts. At tension, deliver an impulse thrust through the arms, trunk, and body. The thrust should be shallow to avoid hyperextension of the patient’s back. The thrust may be applied with a lumbar drop section. This adjustment is commonly applied in the treatment of coupled restrictions in rotation and same-side lateral flexion (PRS, PLS listings)

Knee-Chest

Figure 5-256 Knee-chest adjustment. A, Development of the adjustive contact and use of an adjusting bench in circumstances in which a knee-chest table is not available. B, Hypothenar contact applied to the left L1 spinous process to induce extension, left lateral flexion, and left rotation of the L1–2 motion segment.

P: Establish the contacts on the superior or inferior vertebra of the involved motion segment. When contacting the superior vertebra, the adjustive thrust is delivered anteriorly and slightly inferiorly. When contacting the inferior vertebra, the thrust is delivered anteriorly and slightly superiorly.

Figure 5-257 Bilateral thenar contacts established over the mammillary processes of L2 to induce extension at the L2–3 motion segment.

The patient is instructed to allow the abdomen to drop and, at tension, an impulse thrust is delivered. The patient is vulnerable to hyperextension in this adjustment, so the thrust must be shallow and nonrecoiling.

Figure 5-258 Hypothenar contact applied to the right L4 mammillary process to induce extension and left rotation.

Sitting

Rotation restrictions: When treating rotational dysfunction, the doctor may establish contacts on the spinous process or mammillary process. When using a mammillary contact, establish the contact on the superior vertebra on the side opposite the rotation restriction (side of posterior body rotation). Develop preadjustive tension by flexing, rotating, and laterally flexing the patient away from the side of contact (Figure 5-259, A). At tension, deliver a thrust to induce rotation. This method is applied to induce maximal distraction in the facet joint ipsilaterally inferior to the point of contact. It is also applied to treat restrictions in rotation and same-side lateral flexion (e.g., right or left rotation restriction coupled with the corresponding right or left lateral flexion restriction).

Figure 5-259 A, Hypothenar contact applied to the left mammillary process of L2 to induce right rotation or right lateral flexion of the L2–3 motion segment. B, Hypothenar spinous contact applied to the right lateral surface of L2 to induce right rotation or left lateral flexion of the L2–3 motion segment.

To use a spinous process contact, slide medially and establish a fleshy mid-hypothenar contact on the lateral surface of the spinous process on the side of rotation restriction (side of spinous rotation). Develop preadjustive tension by flexing, rotating, and laterally flexing the patient away from the side of contact (Figure 5-259, B). At tension, deliver a thrust to induce rotation. This contact should induce maximal distraction in the facet joint ipsilateral inferior to the side of spinous contact. This method is also commonly applied when treating combined restrictions in rotation and opposite-side lateral flexion (e.g., right or left rotation restriction coupled with the opposing right or left lateral flexion restriction).

Observation

The alignment of the pelvic ring and sacroiliac joints should be assessed in standing, sitting, and prone positions. Standing postural evaluation has been previously described within the section on evaluation of the lumbar spine (see Figures 5-213 through 5-215). Sitting and prone evaluation of pelvic alignment incorporates an evaluation of the same pelvic landmarks and provides the doctor the opportunity to compare alignment in weight-bearing and non–weight-bearing positions. For example, a low iliac crest standing and sitting may identify a discrepancy in bony symmetry of the innominates versus a discrepancy in leg length. A low iliac crest in the standing position that appears high in the prone position may indicate the presence of sacroiliac dysfunction and a functional short leg versus an anatomic short leg.

Static Palpation

The palpatory assessment of pelvic bony and soft tissue structures is primarily conducted in the prone position. To evaluate the bony landmarks, establish bilateral contacts with the thumbs or fingertips and compare the contour and alignment of the iliac crests, PSISs, sacral base, and sacral apex (Figure 5-269). The palpatory depth of the sacral base just medial to the PSIS and the distance between the second sacral tubercle and the PSIS should be evaluated on each side and compared (see Figure 5-269).

Figure 5-269 Prone palpation of the bony landmarks of the pelvis. A, Palpation of the alignment of the iliac crests. B, Palpation of the alignment of the posterosuperior iliac spine. C, Palpation of the alignment of the sacral apex. D, Palpation of the sacral sulcus. (Note the depth and alignment of the sacral base.)

Flexion (PI) or extension (AS) malpositions of one innominate as compared with the other are possible indications of pelvic dysfunction. These positions of distortion may be identified with the aid of palpation and observation. Table 5-9 lists the clinical findings that have been empirically reported by the chiropractic profession to reflect each distortion. However, remember that identification of altered alignment is not confirmation of dysfunction. The evaluation of alignment, like all physical procedures, is prone to examiner error, and congenital asymmetries of the pelvis are not uncommon.

TABLE 5-9 Clinical Findings Associated with Pelvic Distortion

AI, Anteroinferior; ASIS, anterosuperior iliac spine; PSIS, posterosuperior iliac spine.

The soft tissues of the lumbosacral, sacroiliac, and gluteal regions are also palpated with the palmar surfaces of the fingers or thumbs. In the patient complaining of low back pain, it is important to carefully distinguish between several common sites and sources of pain. Pain arising in the sacroiliac joint, iliolumbar ligaments, lumbar motion segments, or adjacent gluteal soft tissues may all be responsible for the subjective complaint of generalized lumbosacral or sacroiliac pain.

The sacroiliac ligaments are palpated just medial to the PSIS, and the iliolumbar ligaments are palpated between the L5 transverse process and iliac crest. Pain arising from the myofascial origins of the gluteal and piriformis muscles is identified by exploring their attachments along the PSIS, iliac crest, and sacral ala (Figure 5-270).

Figure 5-270 Palpation of the lumbosacral and gluteal soft tissues. A, Palpation for tenderness of the right iliolumbar ligament. B, Palpation of the origins of the gluteal muscles. C, Palpation of the origins of the piriformis muscles.

Incorporated into the evaluation of the bony structures of the pelvis is an evaluation of comparative leg length. Anatomic discrepancies in length may predispose the patient to pelvic dysfunction, and functional leg length inequality is considered a potential significant sign of sacroiliac subluxation and dysfunction. Leg length is traditionally evaluated in the prone position by observing the comparative length of the heels or medial malleoli (Figure 5-271, A). If discrepancies are noted, the legs should be elevated at 90 degrees of knee flexion to screen for a shortened tibia (Figure 5-271, B). The elevated feet must be maintained in neutral upright position. Internal or external rotation of the hip induces a false indication of tibial shortening.

Figure 5-271 Prone evaluation of leg length. A, Knees extended. B, Knees flexed.

In cases of suspected sacroiliac dysfunction and associated functional leg length inequality, the doctor should also evaluate and compare leg length in the supine and sitting positions. Functional leg length inequality that is secondary to sacroiliac subluxation and dysfunction may reverse from the supine to sitting position, whereas anatomic leg length inequality or functional inequality secondary to dysfunction at other sites likely will not (Figure 5-272).

Figure 5-272 Supine evaluation of leg length. A, Lying supine. B, Sitting. C, Changes in leg length observed from the lying to the sitting position may indicate a sacroiliac dysfunction. On the side of the relative posterior innominate (leg A), the acetabulum is displaced anteriorly, creating a leg deficiency in the supine position, which lengthens on sitting.

(Modified from Gatterman MI: Chiropractic management of spine related disorders, Baltimore, 1990, Williams & Wilkins.)

A unique method incorporating prone leg length evaluation is also commonly applied in chiropractic. This method is referred to as the Derifield pelvic leg check (DPLC). This procedure is purported to detect sacroiliac dysfunction and determine the side and nature of the dysfunction. ^85,86 The reliability of DPLC as a separate diagnostic procedure has not been evaluated. The validity of the DPLC to ascertain pelvic dysfunction has not been evaluated.

The test is based on the premise that pelvic dysfunction is associated with misalignment of one ischium as compared with the other, and that pelvic misalignment will be reflected in functional unleveling of the legs. The relative short-leg side is envisioned to be associated with a PI malposition of the ischium. The relative long-leg side is associated with an AS malposition of the ischium.

The DPLC is performed in a prone position and incorporates the evaluation of leg length in a knee-extended position, followed by an evaluation in 90 degrees of knee flexion (see Figure 5-271). If leg length inequality is noted in the knee-extended position, the knees are flexed to 90 degrees to observe for a change in comparative length. A Derifield positive response (D+) is observed when the comparative short leg gets longer. A Derifield negative response (D−) is observed when the short leg remains short or appears even shorter. A D+ indicates that the sacroiliac dysfunction is on the side of the short leg and a D− response indicates that the dysfunction is on the side of the long leg.⁸⁵

The DPLC is theorized to detect pelvic dysfunction as a result of associated reactive hypertonicity in the anterior thigh muscles on the side of sacroiliac dysfunction. When the reactive anterior thigh muscles are stretched in the knee-flexed position, they contract, firming up the thigh and increasing its A-P diameter. The net effect is to elevate the leg of the table on the dysfunctional side. Therefore, on the D+ side, the short leg gets longer, decreasing or reversing the inequality. On the D− side, the long leg gets longer, increasing the inequality. ⁸⁵

Joint Play

A variety of different joint provocation techniques have demonstrated their reliability and validity for identifying the sacroiliac joint as a source of LBP. Many of these procedures can be classified as JP procedures and include compression, distraction, torsion, and shear tests. Palpatory localization of pain to the sacroiliac joint, in conjunction with positive joint provocation testing, should provoke suspicion of the sacroiliac joint as one potential source of the patient’s LBP.

Sitting Joint Play

To assess sitting JP of the sacroiliac joint, place the patient in the sitting position, with the arms relaxed on the lap. Sit behind the patient, shifted slightly to the contralateral side. Establish the palpation contact with the thumb along the medial aspect of the PSIS, with the supporting forearm placed across the patient’s shoulders (Figure 5-273). Guide the patient in lateral flexion away from the side of contact until tension at the sacroiliac joint is felt. At tension, apply additional downward pressure through the indifferent arm, coupled with lateral pressure from the contact thumb. Slight give should be perceived during evaluation, and abnormal resistance or pain may be associated with sacroiliac dysfunction.

Figure 5-273 Thumb contact applied to the right posterosuperior iliac spine to evaluate joint play of the right sacroiliac articulation.

Prone Joint Play

Sacroiliac Flexion

To evaluate flexion JP, reach across with the caudal hand and cup the patient’s anterior ilium. Then palpate the sacroiliac joint with the cephalic hand by locating the fingertips just medial to the PSIS over the dorsal aspect of the ipsilateral sacral ala (sulcus of the SI joint) (Figure 5-274). To execute the procedure, pull posteriorly with the anterior ilial contact and palpate for posterior glide of the ilium. Counterpressure asserted against the sacral base through the doctor’s thenar or hypothenar may also be applied to induce more shear across the joint. Pain indicates that the sacroiliac joint may be dysfunctional and contributing to the patient’s LBP.

Figure 5-274 Anterior-to-posterior pressure applied to the right ilium and digital contacts applied to the right sacroiliac joint assess for the presence of flexion joint play.

Sacroiliac Extension

To assess extension, contact the sacral apex with the caudal hand and a contact on the ipsilateral PSIS with the hypothenar of the cephalic hand (Figure 5-275). Apply anterior and superior pressure against the ilium and anterior and inferior movement against the sacral apex. Normal movement is reflected by a sense of give and separation into extension. Pain indicates that the SI joint may be dysfunctional and contributing to the patient’s LBP.

Figure 5-275 Counterpressure applied through a hypothenar contact over the right posterosuperior iliac spine and a hypothenar contact over the sacral apex to assess extension joint play in the right sacroiliac joint.

Inferior Sacral Glide

The patient is placed in the prone position, and the doctor reaches across the patient with the heel of the caudal hand to contact the patient’s lower ischium. The ulnar side of the cephalic hand contacts the superior dorsal surface of the sacrum, also on the contralateral side (Figure 5-276). To execute the procedure, apply caudal pressure against the sacrum as counterstabilizing pressure is maintained against the ischium. Pain during the test may indicate sacroiliac dysfunction.

Figure 5-276 Hypothenar contact applied to the right sacral base exerts pressure inferiorly against counterpressure applied by a calcaneal contact over the right ischium to assess inferior sacral glide.

Superior Sacral Glide

The patient is placed in the prone position. The doctor reaches across the patient with the ulnar side of the caudal hand to contact the inferior and lateral margin of the sacrum. The cephalic hand stabilizes the iliac crest with a broad contact (Figure 5-277). Cephalic pressure is applied against the sacral contact as counterpressure is maintained against the ilium. Pain during the test may also indicate sacroiliac dysfunction.

Figure 5-277 Hypothenar contact applied to the right inferior margin of the sacrum exerts pressure superiorly against counterpressure applied by a calcaneal contact over the right iliac crest to assess superior sacral glide.

Motion Palpation

Sitting Mobility Test

Sacral Push

The patient is asked to sit with the arms relaxed on the thighs. The doctor sits behind the patient and establishes bilateral thumb contacts across the patient’s sacroiliac joints and sacral ala (Figure 5-278). The patient is then asked to extend back and rotate around the doctor’s thumbs. With proper sacroiliac and lumbosacral joint motion, the doctor’s thumbs should move symmetrically forward with the patient’s sacral base. Restricted anterior gliding of the sacral base may indicate sacroiliac dysfunction.

Figure 5-278 Thumb contacts push posteriorly to anteriorly over the sacral base on both sides to assess anterior glide of the sacrum.

Standing Sacroiliac Tests

Upper Sacroiliac Mobility

The patient is asked to stand, supporting himself or herself by reaching out to contact the wall or a chair. The doctor stands or sits behind the patient and establishes thumb contacts on the patient’s PSIS and second sacral tubercle or ipsilateral sacral base (Figure 5-279). The patient is then instructed to flex his or her ipsilateral hip. This induces flexion of the hip and sacroiliac joint. This procedure may be done with the patient’s knee either flexed or straight. If the patient is instructed to keep his or her knee bent during hip flexion, instruct the patient to raise the hip to approximately 90 degrees. If the patient is instructed to keep his or her leg straight, instruct the patient to raise his or her leg to approximately 45 degrees.

Figure 5-279 Standing sacroiliac joint evaluation for right upper joint movement. After thumb contacts are established over the right posterosuperior iliac spine and sacral tubercle, the patient flexes the ipsilateral hip to assess sacroiliac (SI) joint flexion (approximation of the thumbs) (A) and the contralateral hip to assess SI joint extension (separation of thumbs) (B).

With normal movement, the doctor’s thumbs approximate as the PSIS moves posteriorly and inferiorly toward the relatively stationary second sacral tubercle (see Figure 5-279, A). Sacroiliac flexion restrictions should be suspected when the thumbs do not approximate and the pelvis rotates obliquely around the opposite hip.

After flexion has been evaluated, the patient is instructed to raise the contralateral leg to a level above 90 degrees. This induces posterior nodding of the sacral base and sacroiliac extension on the side of palpation. With normal movement, the doctor’s thumbs move apart as the PSIS moves anteriorly and superiorly away from the second sacral tubercle (Figure 5-279, B).

Lower Sacroiliac Mobility

To assess mobility of the lower sacroiliac joint, the palpation contacts are moved down to the sacral apex and adjacent ischium (Figure 5-280). The patient is again instructed to raise the ipsilateral leg to approximately 90 degrees. Flexion in the lower joint is assessed, and the doctor’s thumbs should separate as the ischium moves anteriorly and superiorly, relative to the sacral apex (see Figure 5-280, A). Extension of the lower sacroiliac joint is evaluated by elevating the opposite leg to a level above 90 degrees. Normal extension of the lower joint is demonstrated by separation of the sacral and ischial contacts (Figure 5-280, B).

Figure 5-280 Standing sacroiliac joint evaluation for right lower joint movement. After thumb contacts are established over the right sacral apex and the soft tissue lateral to the sacral apex in line with the posterosuperior iliac spine, the patient flexes the ipsilateral hip to assess SI joint flexion (separation of thumbs) (A) and the contralateral hip to assess SI joint extension (separation of thumbs) (B).

The standing sacroiliac mobility tests (Gillet tests) have demonstrated poor to mixed reliability and have not been subjected to significant validity testing. They may assist the doctor in refining his or her adjustive approach, but should not be used as a stand-alone procedure for determining whether a patient has pelvic dysfunction.

Sacroiliac Joint Stability Testing

The sacroiliac joint is postulated to have a self-bracing mechanism that is clinically important to proper lumbopelvic function. “The self bracing mechanism is induced through pre-activation of the local muscle system of the lumbopelvic region prior to movement, with subsequent tensioning of the pelvic ligaments, thoracolumbar fascia and compression of the joint surfaces.” ⁸¹ This mechanism induces a close-packed position of the sacroiliac joint (nutation of sacrum and relative posterior rotation of the innominate) to assist in load transverse.

Clinical assessment of sacroiliac stability has been developed (the Stork test). The Stork test is a modification of the standing SI motion test (the Gillet test). During the single-leg standing support phase, the doctor palpates the PSIS and the second sacral tubercle. In a stable sacroiliac joint, the self-bracing mechanism moves the PSIS in a posteroinferior direction or maintains the PSIS in a neutral position. An unstable joint is indicated by anterosuperior movement of the PSIS (positive test). The Stork test has demonstrated good reliability in one study, but has not been tested for validity.⁸¹

Pubic Symphysis Dysfunction

The symphysis is not a synovial joint and, as such, does not demonstrate significant movement. However, some degree of shifting and shearing movement at the symphysis is probably present with locomotion and occurs by virtue of its fibrocartilaginous structure. As a result, dysfunction at this joint may contribute to pelvic dysfunction and pain. The question then remains: If the symphysis is capable of contributing to sacroiliac dysfunction, how does a doctor determine if the symphysis should be manipulated?

Although methods for assessing glide are presented, it is doubtful that mobility at the symphysis is palpable. Therefore, pain on stress testing may be more indicative of dysfunction than misalignment and mobility testing. The final decision as to whether pubic symphysis dysfunction is present is a clinical judgment based on the physical findings and the patient’s prior response to treatment. In cases that are not responding as expected, it may be appropriate to institute a course of trial manipulation of the symphysis pubis after contraindications have been ruled out.

Evaluation of the Pubic Symphysis

Palpation of the pubic articulation must be approached cautiously because of its proximity to the genitalia and its sensitivity to pressure. Palpation of the pubic bone and symphysis can occur through light clothing or a gown. The pubic symphysis should be accessed from the superior direction and its location can be aided by having the patient locate the pubic bone before palpation.

To palpate the pubic symphysis, place the patient in the supine position. Begin by accessing the ASISs of the ilium with the fingertips. Meet the thumbs in the midline superior to the pubic symphysis and proceed inferiorly until the symphysis is contacted. Once the superior margins of the pubic bone are located, the doctor may palpate the anterior aspect of each pubic bone with the thumbs or index fingers of both hands (Figure 5-281).

Figure 5-281 Palpation of the pubic symphysis for pain and displacement. A, Anterior-to-posterior pressure is applied to assess anterior displacement and posterior glide. B, Superior-to-inferior and inferior-to-superior pressure is applied to assess for superior or inferior displacement and glide.

After locating the pubic bone, the doctor should proceed to evaluate alignment and the joints’ response to gentle provocation. Alignment should be assessed for changes in A-P and S-I orientation from one side to the other. Joint provocation is performed by applying gentle A-P and S-I springing movements across the joint. Finally, ask the patient to actively tilt the pelvis sideways or, alternately, elongate and shorten the legs as you palpate for subtle shifting between the two pubic bones. Any direction that causes pain, as well as any movement abnormality, may indicate disease or dysfunction in the pubic articulation.

Evaluation of the Coccyx

External evaluation of the coccyx and its articulation is performed with the patient in a prone position. Begin by palpating the sacrococcygeal joint space for abnormal alignment and tenderness. Apply P-A stress to the sacrococcygeal joint with double thumbs to induce JP movement.

Internal palpation of the coccyx for misalignment or tenderness may be performed in the prone or side-lying position. When performing this evaluation, use the same standards of patient draping and technique that would be used in a digital rectal examination. When patients of the opposite gender are evaluated, it is standard of care that an assistant be present.

With internal palpation, the coccyx can be grasped between the index finger and thumb of the doctor and evaluated for A-P glide and tenderness. Internal coccyx evaluation is most helpful in identifying anterior deviation of the coccyx, posterior glide restrictions, or tenderness of myofascial attachments to its anterior and lateral surfaces. Misalignment with tenderness or loss of JP is characteristic of dysfunction.

Side-Posture Pelvic Adjustments

Side-posture sacroiliac adjustments are the most common manipulative methods used for treating sacroiliac joint dysfunction. Like lumbar side-posture adjustments, they offer flexibility in patient position and added leverage. They can, however, produce unwanted rotational tension in the lumbar spine. This can be minimized by limiting counter-rotation of the patient’s shoulders and by emphasizing traction and tension on the sacroiliac joint through the contact hand.

Prone Pelvic Adjustments

Prone pelvic adjustments can be appropriate alternatives to side-posture pelvic adjustments. They do not produce the preadjustive joint distraction of side-posture adjustments, but they may be more appropriate for situations in which a side-posture position would unduly stress the lumbar spine.

Symphysis Adjustments

The adjustive procedures that are applied to the pubic symphysis often use an initial patient contraction of specific muscles against resistance supplied by the doctor. The muscle contraction first pulls on the symphysis in the desired direction and when, or if, tolerated by the patient, an impulse thrust is applied. This is not a synovial joint, and cavitation is not likely. Sometimes a noise that indicates a soft tissue release or tendinous snap will be heard or felt.

Coccyx Adjustments

Coccygeal pain may occur after a fall or childbirth and can be very persistent. The benefits of coccygeal adjustment will most likely be realized either very quickly or not at all. The external contact uses a tissue-pull procedure and is probably less effective but more comfortable for the patient. The internal contact has the doctor placing a finger intrarectally to establish a contact on the anterior aspect of the coccyx. Use of latex gloves is necessary to provide a sanitary barrier. Appropriate patient gowning and draping as well as a thorough explanation of the procedure is important to maintain professional boundaries. When this procedure is performed on patients of the opposite sex, it is standard of care that an assistant be present.

Side-Posture

P: Place the patient in side posture, with the involved side up. Flex the upper thigh to between 60 and 80 degrees. Establish the ilial and leg contacts and develop preadjustive tension by distracting and extending the involved sacroiliac joint.

Figure 5-282 Hypothenar contact established over the right posterosuperior iliac spine to induce extension of the right sacroiliac joint (posteroinferior ilium).

Produce joint distraction by lowering your body weight on to the patient’s lateral thigh. Produce joint extension by leaning your torso P-A, I-S into the contact. The IH stabilizes the patient’s shoulder and applies gentle traction cephalically and posteriorly. Take care to avoid excessive posterior rotation of the patient’s upper torso. At tension, generate a thrust by dropping upper body weight into the contact. Medial to lateral pressure against the PSIS is an important component of this procedure as it assists in distracting the sacroiliac joint.

Figure 5-283 Hypothenar contact established over the right (A) and left (B) side of the sacral base to induce sacroiliac flexion by inducing posterior-to-anterior movement of the sacral base on the side of contact.

P: Place the patient in side posture, with the involved side up. Slightly flex the patient’s trunk and flex the upper thigh to 90 degrees or more. Establish a broad soft contact along the inferior and medial margin of the ischium.

Figure 5-284 To induce flexion (anterosuperior ilium) of the right sacroiliac joint, a hypothenar contact (A) or a forearm contact (B) is established over the posterior aspect of the ischial tuberosity (C). The doctor’s leg contacts are modified in this adjustment to a straddle-leg position.

Preadjustive tension is produced by inducing sacroiliac distraction and flexion. Sacroiliac distraction is induced by dropping the patient’s flexed thigh toward the floor and by lowering the doctor’s body weight against the patient’s flexed hip. Sacroiliac flexion is induced by maintaining inferior directed pressure with the contact hand as the doctor directs cephalic pressure against the patient’s flexed leg with his caudal leg.

At tension, a body-centered thrust is delivered anteriorly along the shaft of the femur through the trunk and lower extremities. Your lower abdomen may impact the patient’s posterior lateral buttock and hip. A slight variation of this procedure involves using a forearm contact instead of a hypothenar contact (Figure 5-284, B). Optional doctor stances and leg contacts may also be used in this adjustment (Figure 5-284, C).

P: Place the patient in side posture, with the involved side down. Slightly flex the patient’s trunk and flex the upper thigh above 90 degrees. Establish a broad soft contact along the up-side of the sacral apex.

Figure 5-285 Hypothenar contact (A) or a forearm contact (B) is established over the sacral apex to induce extension of the left sacroiliac joint.

Develop preadjustive tension by inducing lumbosacral flexion and forward rotation of the pelvis. This produces posterior nodding and rotation of the sacral base on the down-side and extension of the down-side sacroiliac joint. Induce anterior pelvic rotation by dropping the patient’s flexed thigh toward the floor and by lowering your body weight against the patient’s flexed hip. Induce posterior nodding of the sacral base by pulling inferiorly with the contact hand against the sacral apex as you push cephalically against the patient’s flexed leg with your caudal leg.

At tension, deliver a body-centered thrust anteriorly through the trunk, lower extremities, and shoulder. Your lower abdomen may impact the patient’s posterolateral buttock and hip. A slight variation of this procedure involves using a forearm contact instead of a hypothenar contact (Figure 5-285, B).

Prone

P: Position the patient in the prone position. Reach across the patient with the caudal hand and establish a hypothenar contact on the contralateral PSIS. With the cephalic hand, reach inferiorly to establish a contact on the sacral apex (Figure 5-286, A).

Figure 5-286 Adjustment for restricted extension in the left sacroiliac joint using bilateral contacts over the left posterosuperior iliac spine (PSIS) and sacral apex (A) and a unilateral contact over the PSIS (B).

Develop preadjustive tension by leaning anteriorly and superiorly with the iliac contact and anteroinferiorly with the sacral contact. A pelvic block may be positioned under the greater trochanter to assist in the development of sacroiliac extension. At tension, deliver a high-velocity thrust combined through the arms, trunk, and body.

When using this adjustment with a drop table, place the patient’s ASISs in the break between the adjusting table’s pelvic and lumbar sections. The adjustive thrust should not be delivered until appropriate drop-piece tension has been established.

If desired, a PI ilium or sacroiliac extension restriction may be treated with a unilateral contact on the PSIS. With this method, you may stand on either side of the patient (Figure 5-286, B).

P: Position the patient in the prone position. Reach across the patient with the caudal hand and establish a palmar contact on the inferior ischium. With the thenar or hypothenar of the cephalic hand, contact the superior margin of sacral base just medial to the PSIS on the same side.

Figure 5-287 Adjustment for restricted flexion of the left sacroiliac joint, using contacts over the left ischium and sacral base with blocks (A) or without blocks (B). C, Unilateral sacral base contact.

Develop preadjustive tension by leaning anteroinferiorly with the ischial contact and anteriorly and superiorly with the sacral contact. A pelvic block may be positioned under the ASIS to assist in the development of sacroiliac flexion (see Figure 5-287, A).

At tension, deliver a high-velocity combined thrust through the arms, trunk, and body.

When using this adjustment with a drop table, place the patient’s ASISs at the superior end of the table’s pelvic section. The adjustive thrust should not be delivered until appropriate drop-piece tension has been established.

If desired, a posterosuperier sacral base or sacroiliac flexion restriction may be treated with a unilateral contact on the involved PS sacral base. With this method, you may stand on either side of the patient (see Figure 5-287, C).

P: Position the patient in the prone position. Reach across the patient with the cephalic hand and establish a hypothenar contact on the contralateral PSIS. With the caudal hand, reach across the patient and grip the patient’s contralateral thigh just proximal to the knee.

Figure 5-288 Contact over the left posterosuperior iliac spine while extending the hip to induce extension of the left sacroiliac joint.

Develop joint tension by leaning into the contact and gently extending the patient’s thigh. The patient’s knee on the elevated side may be flexed or remain extended. Accompanying hip extension is minimal and should not elevate the patient’s pelvis off the table.

At tension, deliver an impulse thrust through the ilial contact, reinforced by a shallow lift with the thigh contact. The thrust through the hip must be shallow. It is possible to overextend the hip, damaging the capsule and its adjacent soft tissues. This adjustment is contraindicated in patients with hip pathology or meralgia paresthetica.

When using this adjustment with a drop table, place the patient’s ASISs in the break between the adjusting table’s pelvic and lumbar sections. The adjustive thrust should not be delivered until appropriate drop-piece tension has been established.

P: Position the patient in the prone position on a padded board. Place a padded wedge under the ASIS on the side of the anterior innominate and another under the anterior aspect of the hip on the side of the posterior innominate to develop sacroiliac flexion.

Figure 5-289 Prone pelvic blocking for a left anterosuperior and right posteroinferior distortion pattern, using gravity over time to induce movement at the sacroiliac joints. There is no thrust.

No thrust is given; gravity provides the force applied over time. This procedure does not fit the definition of an HVLA adjustment because of the lack of a high-velocity thrust.

Supine

Figure 5-290 Left superior pubis adjustment.

Figure 5-291 Right anterior pubis adjustment; also an alternative for a right superior pubis adjustment.

Figure 5-292 Right inferior pubis adjustment.

Figure 5-293 Pubic distraction.