The Hip Joint: Myofascial and Joint Patterns

By Marc Heller, DC

The hip joint is an absolutely critical component of both lower back and lower extremity problems. I want to share what I have learned recently. First, it's important to note a couple of studies that confirm the importance of the hip.

Increased hydraulic pressure in the hip joint capsule is associated with increased pain, and this increased pressure decreases circulation and is probably associated with increased degenerative changes.¹ Can soft-tissue-oriented therapy change a chronic hip-pain pattern, once degenerative changes have occurred? Another study, involving patients with advanced hip degenerative changes, showed that trigger-point injections with stretching, administered to a series of muscles, gave long-term relief.²

Addressing the hip joint is important in many cases, not just patients who complain of hip or groin pain. In another fascinating study,³a clinical prediction rule, therapists looked at which patients would respond most consistently to a simple lumbar manipulation. They found that one of the significant factors was normal hip internal rotation. Think outside the box and reverse this. It implies that in the tougher cases, those that need more comprehensive care, patients lack normal hip internal rotation.

Let's look at the hip joint and how to address it. Over the years, I have noticed two very common subluxation patterns in the hip. The first is a lack of internal rotation. This fits the Cyriax capsular pattern, in which internal rotation is the first motion lost in hip joint problems. When you find a severe lack of internal rotation in the hip and this motion cannot be restored, the patient is usually on their way to hip replacement surgery, sooner or later. If you can restore near-normal motion, the hip-related pain usually will improve, and hip surgery can be avoided or at least delayed. In my clinical experience, I have found this lack of internal rotation to be clinically significant and very helpful in establishing a prognosis.

The second subluxation pattern seen is a lack of anterior-to-posterior motion, and what you might call an anterior hip. I'm not usually a fan of muscle-testing indicators (where weakness "A" means dysfunction "B"), but I make an exception in certain cases. Lucy Whyte Ferguson, in a chapter on the hip in her book Clinical Mastery in the Treatment of Myofascial Pain,⁴describes weakness of the hip flexors, including the psoas, rectus femoris or TFL, indicating that the hip joint is dysfunctional. I was taught this many years ago,⁵ and it's one of the findings that has stood the test of time in my own practice.

Over the years, I have looked for these two subluxation patterns and corrected them,⁶ and seen good changes in my patients. Then I read Dr. Whyte Ferguson's chapter on the disordered hip complex and the whole picture suddenly became much clearer. Dr. Whyte Ferguson puts the whole thing together. She talks about these two joint patterns and sees them as one - a combination of positional external rotation and anterior subluxation that leaves the head of femur on the anterolateral edge of the acetabulum, not fully "seated." I'll describe how to correct this later in the article.

Myofascial Components of Hip Pain

The myofascial component is critical to correcting the dysfunctional hip. Before reading Dr. Whyte Ferguson's work, my focus was on the obvious tight muscles behind the trochanter. This includes the gluteal insertions, the piriformis and other external rotators. There are other critical muscles. Dr. Whyte Ferguson outlines what she calls the "bowstring" and "rubber band" metaphors; how the hypertonic psoas and adductors pull the head of the femur out of position.

If you understand the biomechanics of the bowstring metaphor, it will change how you look at the hip forever. Think about the psoas and the adductors. Both frequently are tight, and both have significant myofascial shortening. The psoas inserts at the lesser trochanter. When it is tight, it pulls the femur in an anterolateral direction. This is reinforced by the adductors, which are pulling the shaft of the femur in a medial direction. The combination of these two pulls shifts the femur in its socket, leaving the femoral head stuck more anterior and more lateral than it belongs. This model makes so much sense clinically.

What muscles should you assess and release? As mentioned, key muscles include the adductors, the psoas and iliacus, the gluteus medius and maximus, as well as the piriformis, quadratus femoris and the other small external rotators of the hip. Don't forget the TFL and the iliotibial band. Dr. Whyte Ferguson introduces a different way to evaluate trigger points and tight bands. Instead of evaluating while the muscle is at rest, she moderately stretches the muscle, and then palpates for tight bands. You are not taking the muscle to a fully stretched position, just a partial stretch. When I first tried this on the adductors, it was like a light- bulb went off. You'll find many more trigger points and tight bands.

What does the patient need to do? First, avoid any exercises (such as a sitting adductor stretch) that take the hip into external rotation, at least until the hip joint is stable. Second, the patient needs to learn to use their hip and buttock muscles properly. This is beyond the scope of this article, but think of a proper hip hinge in getting up and down from sitting, and look at the spine length squat in my article on pain-relief exercise.⁷ The spine length squat emphasizes firing the core while internally rotating the hips, and pushing the buttock posterior to emphasize the lumbar curve.

Adjusting the Hip

Dr. Whyte Ferguson describes an elegant adjustment using eccentric contraction of the adductors to help the practitioner guide the hip back into a properly seated position, simultaneously correcting both the anterior and the external rotation parts of the subluxation pattern. She calls it the "wishbone maneuver." In this manipulation, you take the hip from near-neutral into flexion, abduction and internal rotation, while the patient resists your action by eccentrically activating their adductors.

The patient is lying supine, with the legs hip-width apart. The following example will address the right hip. The clinician starts off facing perpendicular to the table. With your active right arm, cradle the patient's bent knee, supporting the leg both above and below the knee. Begin to lift the whole leg into slight flexion, slight abduction and slight internal rotation. Your other hand holds the left leg down on the table. (I have modified this maneuver, as I don't like to bend over - I just leave the other leg on the table.) You instruct the patient to use their muscles to pull the right knee toward the left knee. Find the verbal cue, knee to knee, or leg to thigh, that works best for the patient. Ask them to continue to do this as you move the leg. Take the whole leg smoothly into further flexion (ending between 90-110 degrees), abduction of 30 degrees and as much internal rotation as you can create without excessive force or stress. You end up facing toward the patient's feet.

You can retest to see if your adjustment was successful via changes in tenderness over the anterior femur, increases in internal rotation, and immediate changes in strength of the hip flexors. I have been very pleased with the profound changes in motion and end-feel that this adjustment creates. Addressing the hip joint and its surrounding musculature seems to have a lasting effect.

This adjustment is unique. It will take you a few cases to get competent. It really is different to move a large limb while the patient continually pulls in the opposite direction. You need the patient's cooperation, coaching them to provide the "just right" amount of correction while you move the hip. It is not exactly muscle energy and it's not contract-relax; it's an eccentric long-lasting contraction during your mobilization. By having the patient actively contract all the way through the motion, the eccentric action of the adductors helps reset the joint. I suspect activation of the patient's internal rotators strongly inhibits the tight posterior hip muscles.

Read Dr. Whyte Ferguson's recent article in the Journal of Bodywork and Movement Therapies,⁸ or better yet, the chapter on the hip in her book. Both of these describe these maneuvers and her overview of the disordered hip complex.

Low-force techniques have changed over the past 20 years. Chiropractors tend to think of the Activator or other adjusting instruments. You can integrate soft-tissue work with the adjustment. These techniques involve a more gradual motion that stretches the soft tissues as you move the joint. They involve some form of activation of the surrounding musculature, whether the contract-relax of muscle energy, the eccentric contraction with movement of the wishbone maneuver, the mobilization with movement of the Mulligan technique, instrument-assisted soft-tissue mobilization with provocation, or resistance and movement as taught in the third-level Graston technique class.

There is a theme here, and it goes something like this: Activate the whole neuromuscular axis as you treat. Re-educate the sensory and motor feedback loops as you adjust. Give the receptors, motor neurons and the whole neuraxis a completely different experience, so the body can reprogram its motion patterns.

References

1. Goddard NJ, Gosling PT. Intra-articular fluid pressure and pain in osteoarthritis of the hip. J Bone Joint Surg Br, 1988;70:52-55.
2. Imamura S, Riberto M, Fischer A, et al. Successful pain relief by treatment of myofascial components in patients with hip pathology scheduled for total hip replacement. J Musculokeletal Pain, 1998;6:73-89.
3. Flynn T, et al. A clinical predictionrule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine, Dec. 15, 2002;27(24):2835-43.
4. Whyte Ferguson L, Gerwin R. Clinical Mastery in the Treatment of Myofascial Pain.Lippincott, Williams & Wilkins, 2005.
5. Thomas M. Lower extremity adjusting seminar, 1998; Eugene, Ore.
6. Heller M. "The Hip Joint." Dynamic Chiropractic, Sept. 13, 2004.www.chiroweb.com/archives/22/19/15.html.
7. Heller M. "Pain Relief Exercise: The Lower Back." Dynamic Chiropractic, Nov. 7, 2005.www.chiroweb.com/archives/23/23/11.html.
8. Whyte Ferguson L. Knee Pain, Addressing the interrelationship between muscle and joint dysfunction in the hip and pelvis and the lower extremity. Journal of Bodywork and Movement Therapies, 2006;10:287-296.

Functional Impingement of the Hip (Part 2): Rehab Exercises

I find functionally impinged hips that don't move properly on so many of my patients. (See part 1 of this article for a description of the condition.¹) Without correcting this anterior hip pattern, these patients are probably doomed to recurring hip pain, medial knee pain and/or lower back problems. Fortunately, we can help.

Why is proper hip motion so important? The hip does not have to hurt when it is dysfunctional. My patients are often surprised by their lack of hip motion. Here is Mike Boyle's take on this from his "joint by joint" approach to training:² "The interesting part lies in the theory behind low back pain. My theory of the cause? Loss of hip mobility. Loss of function in the joint below (in the case of the lumbar spine, the hip) seems to affect the joint or joints above (lumbar spine). In other words, if the hip can't move, the lumbar spine will. The problem is that the hip is built for mobility, and the lumbar spine for stability. When the supposedly mobile joint becomes immobile, the stable joint is forced to move as compensation, becoming less stable and subsequently painful."

Step 1: Assess Hip / Pelvic Motion

I am assuming you have already performed the exam, including ROM, palpation and muscle strength testing for the hip itself. Now let's outline functional tests in all three motion planes, focusing on the hip and pelvis.

Start with the sagittal plane. Can the patient begin a squat by hinging at the hips? A little coaching is OK if they understand it quickly. If not, they need to work on this basic motion. This piece is critical for both the hips and for any flexion-intolerant back.

Does the patient have stability in the transverse plane? Can they lie on their back and raise the foot of one bent leg slowly, without rotating their pelvis? A more advanced version of this test is a single-leg bridge, looking at form and watching the pelvis. If the patient fails these tests, it indicates a lack of proper gluteal and lumbar stabilizer muscle firing, impacting the ability to control axial rotation.

Let's move on to the frontal plane. Test the gluteus medius by observing gait; by observing as the patient performs one-leg standing and one-leg squats. Does the non-stabilizing leg drop inferior in the frontal plane? If so, the gluteus medius on the stabilizing side is weak. Place the patient on their side and muscle test the gluteus medius. Is it weak? Test their ability to hold a side plank. If they cannot hold a straight-leg side plank with good form for 60 seconds, their "side core," the quadratus lumborum and associated muscles are not doing their job.³

When I find functional hip impingement, addressing all three motions around the hip simultaneously seems to be very effective. If I am working with an exerciser, a yogi, an athlete, etc., I may move directly into the two complex, multi-directional functional exercises described in the next few paragraphs. If I am working on a sedentary patient, I probably need to peel back and start with simpler, unidirectional exercises.

Step 2: Newer Rehab Approaches

For years, I have been addressing the hip by teaching the patient to strengthen their gluteus medius and psoas, and to activate the whole posterior chain. But I was unsatisfied with the effectiveness of the rehab component. The goal: exercises that would dramatically and immediately change the hip motion pattern. When the patient sees and feels this, compliance improves immensely.

The following two exercises address the hip in a more functional manner, moving the pelvis against a fixed thigh. Both are complex multi-muscle, multi-function, multi-joint exercises. These exercises can dramatically and immediately change hip function in the right patient.

In the app version of this article, I've included a short video of a brief before-and-after exam of a 73-year-old patient who recently underwent left hip replacement surgery. After five months of hip pain, he worried his hip replacement had failed and had new X-rays taken. The surgeons reassured him the bones were OK. Yet he still experienced hip pain, with one episode bad enough that he could not bear weight. The only treatment between the before and after assessment videos: two repetitions of the side plank "plus" (described in the next section and also called the low diagonal oblique sit). This exercise produced dramatic changes in all of the indicators: strength, ROM and tenderness.

I do wish this exercise were simpler to perform, but it is definitely worth teaching. If you demonstrate to the patient how effective it can be, they will do it. Within a few weeks, three visits and daily performance of these exercises, his hip motion had normalized. (Now it's time to address his inhibited and atrophied glutes and psoas, another side effect of five months of pain.)

What is different about these two exercises? Quoting from Craig Liebenson and Koichi Sato's recent article: "Hip and groin issues are common in both sedentary and active people. Most exercises for this region involve moving the thigh (femur) in/out (adduction/abduction) or forward/backward (flexion/extension). In each of these motions the thigh moves against the pelvis. Yet, in walking, running, kicking, throwing, etc. much of the athleticism or power comes from pelvis moving against a fixed thigh."⁴

These two exercises fit the above criteria. They both have the pelvis moving on the fixed thigh, activating the glutes, adductors and trunk in a different way.

I have become a teacher and proponent of activating and waking up the muscles, to produce length with strength. I rarely teach passive stretching. I've talked about this before,⁵ and the more I learn, the more convinced I am of the utility of this approach. In relation to the dysfunctional hip, the tight adductors need to wake up with activity, not just stretching.

Two Great Multi-Function, Multi-Directional Hip Exercises

Side Plank Plus (Low Diagonal Oblique Sit): This is not a simple exercise; it has multiple distinct steps. It includes a bent-knee side plank (activating the QL area), a roll of the hips in the transverse plane, an activation of the glutes to isometrically push the thigh forward, and activation of the adductors. It may be ideal to stage this – to first teach the patient a side plank and then add the additional motions.

The best description of this exercise is by Liebenson and Sato.⁵ I've also created a YouTube video demonstrating how to perform it. The following description is for the left side. The patient should be side-lying with the left side down, propped up on their left forearm. The legs are both bent, with the right leg behind the left leg.

1. Patient starts by pushing the left forearm into the floor to lift their upper trunk up. I like to add what McGill calls an anti-shrug here, activating the left-side lats to further stabilize the shoulder.
2. Lift the pelvis off the floor, as in a bent-knee side plank. Both knees remain on the floor.
3. Rotate the trunk forward, bringing the right side of the pelvis anterior (transverse plane rotation). This activates the adductors on both sides, and also provides the leverage needed for the next move.
4. Activate the left glutes to push the left thigh forward, pushing the left knee anterior. I recommend that the patient push the lower knee into a wall or couch. (The video does not show this.) Patient should hold this for 10 seconds.
5. Lift the left foot slowly up and down 3- 5 times. Some patients can barely lift the foot; for others it is easier.
6. Repeat the entire exercise sequence three times, twice per day.

Woodpecker Plus: Here's another powerful functional exercise for the hips, done weight-bearing. It is called the "woodpecker with twist" in foundation training.⁶ (Description is for left side.)

1. Focus first on getting the patient into a lunge variation with 80 percent of the weight on the front leg. The front leg is only slightly bent, and the knee is over the heel; don't let the knee go too far forward. On the back leg, the patient is up on their toes, with the toes pointing straight forward.
2. Here is the challenging part; Stick the butt out and do a deep hip hinge; this is challenging to do in the lunge position. If the patient has performed proper squats, they will have a better time understanding this motion.
3. Bring the arms up to 90 degrees of flexion, straight in front. Now, rotate the trunk and arms toward the front leg's side. Most patients want to twist too far. Keep the arms framed with the trunk motion; if their trunk can twist 15 degrees, the arms twist 15 degrees. Activate the inner thighs to isometrically pull toward each other. The front / left leg is active; it stays straight ahead. The front leg's isometric activation is a hidden activity. In stabilizing against the twist of the trunk to the left, the patient is activating the left glutes and adductors; key hip muscles. They should feel this in their left glutes if done correctly.

As with most foundation training exercises, you don't just assume the position; you actively fire multiple muscles isometrically. (Watch my YouTube video courtesy of the DC app.) The patient should do this on both sides, with emphasis on the dysfunctional hip side. Do three reps, holding each for 15 seconds, twice per day.

Unidirectional Exercises; Everyone Has to Begin Somewhere

Earlier, I outlined hip and pelvic evaluation in three planes. It would be incomplete to just tell you about these two complex exercises. A series of simpler exercises are useful for any hip problem. I'll start with two sagittal plane exercises you may not be using. One is the quadruped sit-back, with the patient focused on hip awareness, from Shirley Sahrmann. This exercise is designed to increase awareness of the hip's motion within its socket in an easy, safe quadruped position. (There's a video demonstrating this exercise as well.)⁷

Another useful one is a standing hip flexor endurance exercise, introduced to me by Michael Boyle, who talks about why this is important in the referenced post.⁸ Boyle divides the five hip flexors into two groups. The first group includes the iliacus and psoas, which can lift the hip above 90 degrees. The second group is the TFL, rectus femoris and sartorius.

One of the few stretches I routinely suggest is stretching of the hip flexors, based on measuring their length. I think the hip flexors, seen as a group, tend to get both weak and tight. If the hip flexors are too short, they prevent normal hip extension motion.

Other basics include gluteal strengthening exercises for both the gluteus maximus and gluteus medius. Gluteal function affects all three planes of motion. Remember, pain and improper motor function around the hip or lower back will contribute to gluteal amnesia. Exercises include bridges, one-leg bridges, clamshells and side steps. Don't forget the side plank for the frontal plane.

As always, I suggest an assess, treat, reassess protocol. Use exercise as the treatment. Recheck hip function after the patient has performed the various exercises. Customize your exercise prescription based on what works for them, taking into account the patient's level of motor control.

References

1. Heller M. "Functional Hip Impingement (Part 1): Evaluation, Hip Sparing and Mobilization."Dynamic Chiropractic, April 15, 2015.
2. Boyle M. "A Joint-by-Joint Approach to Training." Blog post available atwww.strengthcoach.com.
3. Liebenson C. Rehabilitation of the Spine. Lippincott, Williams and Wilkins, 2007: p. 244.
4. Liebenson C, Sato K. "The Low Diagonal Oblique Sit Exercise." J Bodywk Movement Ther, 2014;18:643-645.
5. Heller M. "Stop Stretching - or at Least Stop Stretching the Lower Back Into Flexion and Rotation." Dynamic Chiropractic, Dec. 2, 2012.
6. Eric Goodman, DC, developer of foundation training (www.foundationtraining.com).
7. Fox C. "A Multi-Use Exercise: Quad Rock Back." Blog post available atwww.thestudentphysicaltherapist.com.
8. Boyle, M. "Understanding and Training Hip Flexion." Blog post available atwww.strengthcoach.com.

Anterior Femoral Glide Syndrome

By Marc Heller, DC

I am not a chiropractic philosophy writer, but once a year my editor cuts me a little slack. If I am a good chiropractor, it's because of my failures. I learn the most from the patients who I couldn't help initially: the tough cases, the ones in which I wrack my brain to figure out what I am missing.

These tough cases, the ones that require you to think out of the box, are the ones that push you, if you are willing. It's easy to just keep adjusting them, work out the same trigger points, and convince yourself that one more or 10 more treatments will solve the problem, but that doesn't usually work. A recent study tells us that we can predict by the second visit which patients will respond best, at least in cases of lower back pain.¹ The study implies to me that when the patient is not improving quickly, you have to look with new eyes. What I would suggest is that you go back, re-examine them and think of the whole kinetic chain, maybe even the patient's biochemistry and underlying emotional pieces.

At the bare minimum, I believe we need to be experts not only at manipulation, but also at addressing soft tissue and rehabilitation. If the goal is to restore more normal motion, thus improving function and reducing pain, all three of these pieces are necessary.

An accurate musculoskeletal diagnosis includes not only what joint is not moving, but also what joint is moving too much, what specific tissues are the pain generators, and what movement or lack of movement is stressing the pain generator. Shirley Sahrmann states, "A joint develops a directional susceptibility to movement, which then becomes the 'weak link' and most often the cause of pain."²

We have to become more evidence-based. At the same time, we shouldn't become handcuffed to what is absolutely certain. Musculoskeletal research is difficult to do, and its particularly difficult to look at the big picture: the integration of the multiple factors that can contribute to ongoing or recurrent pain syndromes. As Craig Liebenson states, "Lack of evidence of effectiveness is not the same as evidence of ineffectiveness. According to Lewit, we work at the level of acceptable uncertainty."³

Many of you have followed my interest in the hip joint. I am grateful for the contribution of Lucy Whyte Ferguson, DC.⁴ Even using trigger-point work and manipulation of the hip with the wishbone maneuver, as outlined by Dr. Whyte Ferguson, I found too many patients' hip problems recurring, and too many for whom I could not consistently restore normal motion.

I was introduced to a model from Sahrmann that made sense of the two patterns I have seen in the hip. She calls it the anterior femoral glide syndrome, and mentions an internally rotated version and an externally rotated version. Sahrmann's model talks about what accessory movements are dysfunctional. In anterior femoral glide syndrome, the proximal femur moves improperly during hip flexion. Instead of gliding posterior to provide room for the flexion, it glides anterior, jamming into the anterior hip capsule and causing pain and limitation of flexion. What causes this? Sahrmann talks about familiar muscular imbalances. The hamstrings are too tight and are not balanced by the gluteus maximus. During hip extension, the hamstrings create a bowstring effect, pushing the femoral head forward. The posterior structures around the hip are too tight, contributing to the anterior motion. The psoas is weak and long, allowing the forward motion and not stabilizing the hip up into its socket. This view of the psoas is consistent with Sean Gibbon's point of view. He sees the psoas as a local and global stabilizer, likely to be inhibited.

Sahrmann looks at two versions of this hip joint problem. In the first, which she describes as more common, the femur tends to be medially rotated. This tends to occur more in females and goes with genu valgum, pronation, and anteversion of the hip. In this pattern, there is a clear dominance of the tensor fascia latae (TFL) over the gluteus medius, thus pulling the hip into medial rotation. The hip external rotators are likely to be weak. The medial hamstrings are dominant over the lateral hamstrings. Whenever the patient stands on the affected leg, the hip is internally rotated; the hip rotates more easily into internal rotation than external rotation. If you have the patient step up onto a step, you'll see a sudden medial rotation motion at the knee on the involved side.

The second version is the one I am more familiar with, perhaps because it is my own pattern. It involves an externally rotated femur which lacks medial rotation. It's more of a male problem, and is consistent with a more rigid overall structure, one that may include a supinated foot. Sahrmann states that the groin pain is more medially located in these patients. These are the patients for whom the wishbone maneuver, a mobilization with eccentric muscular activity, seems to be most effective.⁵

In both of these anterior femur problems, the pain is likely to start in the groin and then spread to the whole hip. These patterns can be the missing link in lumbar and sacroiliac conditions, as well as with lower extremity problems.

Psoas, Psoas, Psoas

Weakness of the psoas is an important factor in these anterior hip patterns. Sahrmann talks about this, but her book is seven years old now, and there is new research and new methods to rehab the psoas. I recommend you read Sean Gibbons' long article on the psoas.⁶ I used to think of the psoas as an overactive hip flexor. I now think of the psoas as an inhibited lumbar spine and hip stabilizer. If the psoas is not able to contract in a timely manner, the femoral head will drop anterior and lateral, jamming into the hip capsule. Psoas weakness also plays into lumbar instability patterns. Gibbons' model for testing the psoas involves testing lumbar stability and seeing if psoas contraction can change the palpatory feel of lumbar hypermobility. I suspect that we can test the psoas in a different way, testing the effects of psoas weakness on the insertion rather than the origin.

Here is my hypothesis about another way to test the psoas. If the patient has a hard time flexing the involved hip, teach them to contract the psoas, ideally both supine and side-lying. Have them fire the psoas for a few repetitions, correcting for substitution and not overfiring. Local stability exercises often feel so mild that the patient wants to work too hard. To understand this model of how to rehab the psoas, see my description below, Gibbons' article, and/or print the handout from my Web site.⁷

First, the patient has to understand the exercise and be able to do it at least close to correctly. Then have them hold this mild psoas contraction supine, and simultaneously flex the hip, either passively or actively. If this makes the hip easier to flex, with less of a groin pinch, it shows that the psoas is dysfunctional, and needs rehab. I love to show my patients exercises that make an immediate difference in their symptoms or signs. It's the best rehab motivator I know.

The basic exercises to retrain or recruit the psoas are deceptively simple. Suck the hip gently up into the socket, primarily using the psoas. The doctor should initially provide a gentle traction down the long axis of the hip to increase proprioception. Here's the tricky part: You have to suck the femur up into its socket without hiking the hip (which indicates overactivity of the iliocostalis lumborum and/or the quadratus lumborum). You have to activate the psoas without overactivating the TFL and/or the rectus femoris.

While lying supine, raising the upper body up onto the elbows may help take out the hip hikers. Externally rotating the thigh may help take out the TFL and/or rectus femoris. It's OK initially to fire the rest of the inner core while activating this, using the pelvic floor (Kegel), the lower abs and the multifidi. The local stabilizers are all going to inherently co-contract.

The goal, ideally, is to isolate the psoas as much as possible. Another good position for psoas rehab is side-lying, drawing the hip into the socket. In this position, the key is to control pelvic rotation. Personally, I found these exercises somewhat difficult to learn but rewarding. Once you have the basic motion down, you can integrate it into more global hip flexion.

Another Hip Mobilization Method

One aspect of this problem is that as the distal part of the femur flexes, the proximal convex femur head in the concave acetabulum has to rotate and glide in an inferior direction. If this doesn't happen, you get that feeling of jamming in the groin. One way to correct this is via the Mulligan concept.⁸ Mulligan's model basically says to find a direction of passive pressure (applied by either the doctor or the patient) that allows more joint motion. Repeat that assisted motion over and over to reset the neuromuscular system.

In this case, a superior-to-inferior pressure on the proximal hip usually allows for easier hip flexion. You can provide this with manual pressure; use a wide belt to pull the proximal hip inferior. You can follow this up with home self-mobilization procedures. The patient can use the heel of their own hands, pressing inferior while they lift the leg. The patient also can use a belt, strapped from the involved groin down to the opposite foot, to provide the same superior-to-inferior pressure while flexing the hip.

These simple techniques often have dramatic benefit. Try them out. Have fun integrating them into your practice; your patients will thank you for it.

References

1. Malmqvist S, Leboeuf-Yde C, Ahola T. The Nordic back pain subpopulation program: predicting outcome among chiropractic patients in Finland. Chiropractic & OsteopathyNovember 2008;16:13.
2. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby, 2002.
3. Liebenson C. Comments on Spinedoc Web discussion group, Oct. 30, 2008.
4. Whyte Ferguson L. Knee pain: addressing the interrelationship between muscle and joint dysfunction in the hip and pelvis and the lower extremity. Journal of Bodywork and Movement Therapies 2006;10:287-96.
5. Heller M. The hip joint: myofascial and joint patterns. Dynamic Chiropractic, May 7, 2007.www.dynamicchiropractic.com.
6. Gibbons S, Comerford M, Emerson P, et al. Rehabilitation of the stability function of psoas major.
7. www.marchellerdc.com/pro_resources/Articles/#Ex.
8. www.bmulligan.com/about/concept.html.

The Internally Rotating Hip

By Marc Heller, DC

What happens when the hip tends toward internal rotation? This muscular imbalance can create pain in the anterior hip or groin, especially during flexion. This condition can also create posterior hip pain, masquerade as a vague sciatica, and/or contribute to chronic SI dysfunction and medial knee pain, ankle, or foot pain.

I wrote about Sahrmann's¹ concept of the anterior femoral glide back in January.² The medial rotation version of anterior femoral glide is the focus of the current article. In Sahrmann's view, there are two basic patterns of hip joint dysfunction. In both, the hip is usually stuck forward - the anterior femoral glide component. The pattern we are concerned with here involves too much internal rotation. This is more common in females, and correlates with pronation in the foot with medial knee pain, genu valgum and increased Q angles. The other pattern involves excessive external rotation and a lack of internal rotation in the hip joint, as I have written about previously.³

I experienced an epiphany while writing this article. I realized that for far too long, I missed this condition frequently in my patients. I just didn't "get it." My study group colleagues, and Shirley Sahrmann, describe the internally rotating hip as more common than the hip stuck in external rotation, but I was only rarely seeing it.

So, why was I missing this? Two reasons: First, I personally have a symptomatic externally rotated hip, so that experience tends to affect my "filters." Second, I am a chiropractor; I have a hard time with a condition that doesn't need an adjustment. If all you have is a hammer, everything looks like a nail. Even though I write about the importance of soft tissue and rehab, a condition that needs only soft tissue and rehab can escape my view. I've gotten over this blindness in the shoulder, in the elbow and the Achilles, all places where tendonosis responds so well to cross-frictional massage, but the internally rotated hip escaped me for a long time.

The internally rotated hip is primarily a muscular imbalance. The hip may lack external rotation, but not necessarily. The hip may have a hard end feel in either internal or external rotation, and the hip may be jammed forward in an anterior femoral glide. You cannot find this condition via palpation of any joint dysfunction. If it's strictly a muscular imbalance, you just need to release the tight soft tissues, and retrain and activate the inhibited muscles.

Diagnostic Considerations

The only way I know of to identify this condition is through a weight-bearing functional test. Here are the two variations I use. The patient is standing, and you ask them to do a lunge; to step forward with the front knee bent. You observe the forward knee, watching to see if it momentarily medially deviates. If the patient is stable on the forward knee as they do this, they have passed the test. If they are unstable on the front knee, with wobbling in the knee, especially in a medial direction, they probably have an internally rotated hip. You could also instruct them to step forward and up with one leg onto a small stool, and observe for the same medial deviation.

Other indicators include tests that identify the muscular imbalances more directly. Are the tensor fascia latae (TFL) and rectus femoris tight and short? This can be evaluated through the modified Thomas test and palpation. Are the gluteus medius and hip external rotators (piriformis, obturators, gemelli, and quadratus femoris) weak? The weight-bearing lunge test described above is directly aimed at identifying this weakness in a functional manner.

Fig. 1You can muscle test the deep lateral rotators. Have the patient sitting with their legs dangling. Then have them rotate inward with their foot against your resistance. Pushing the foot inward externally rotates the hip. Can the patient do this, especially at the end range? A muscle that has a chronic stress strain will be weak at end range. The clam shell exercise/test can be useful to identify this weakness as well, especially if you keep the patient's pelvis in neutral and don't let them rotate their pelvis backward as they lift their bent knee.

The Anterior Femoral Glide Component

The second component that usually accompanies the internally rotating hip involves an abnormal pattern of hip flexion. I discussed this in my anterior femoral glide article earlier this year. As the hip flexes, the proximal hip should drop backward, allowing freedom of hip flexion. This doesn't happen when the TFL and rectus femoris are too tight.

Fig. 2Hypertonic hamstrings can also contribute to this pattern. As you passively flex the hip, the patient will complain of groin pain. The patient will typically be tender to palpation over the femoral head.
You can easily determine whether an inferior-posterior glide will improve the hip flexion. As the patient flexes their upper leg, push the superior part of the femur inferior. (This would be a posterior pressure if the leg were straight.) If part of the problem is an anterior femoral glide, this pressure will ease the pain of hip flexion.

This can be useful as an assessment tool, as an in-office maneuver and as a home exercise. It may lend itself to anterior to posterior mobilization, and teaching the patient to mobilize the hip anterior to posterior during flexion.

The two images above show two variations of exercise specifically to help this proximal hip glide. One uses a strap as the patient flexes. [Figure 1] This exercise can be done with the patient just holding the flexed position, as a long (2-minute) stretch, as shown in the picture. It can also be done as a self-mobilization with movement, having the patient further flex and then release the hip, with the strap as a fulcrum to guide the proximal hip inferior-posterior. The second exercise, a variant of child's pose from yoga, puts the body in a position to glide the proximal femur posteriorly. [Figure 2] To perform the exercise, the patient goes from a 90 degree position back to 120 degrees.

Soft-Tissue Treatment and Rehabilitation

Releasing the tissues of the obturator foramen seems to be very helpful for hips that are rotating internally. Despite the fact that in this model, these muscles are seen as weak, manual therapy with movement clearly seems to help. This is one of those sensitive areas most DCs don't touch. I suggest you observe a few cautions if you decide to examine and treat here. One, tell the patient what you are doing and why before you begin. Two, keep your hands on the lateral side of the pubic and ischial ramus. Never go medial to the bony structures.

The obturator muscles, both the internus and the externus, are involved. I contact the obturator foramen with my thumb or index finger. Remember to be gentle, especially in your first touch, as this is a sensitive area. The patient is supine in a hook-lying position. They can relax their bent leg outward as you support this area with your thigh. In this position, they are relaxed and the pelvis is open enough to easily get to the obturator.

I start with a contact on the lateral portion of the pubic symphysis, follow the pubic ramus slightly lateral, and then drop inferior toward the obturator foramen. The contact presses superior and medial. You'll feel as though your finger or thumb is pressing into a trampoline. Look at a 3-D model and see how the obturator foramen faces inferior and lateral. I will vary the exact location of my contact to find the most tender area in the foramen. It could be central, more medial or more superior-medial.

I maintain this contact and then have the patient actively push their knee outward against my resistance, creating external rotation in the hip. It's not just isometric; have them move a few inches and you'll feel a muscular activation under your contact hand. It's the obturator muscles that are firing. If this area is significant, you may get better range of motion after performing this procedure.

The other critical muscle to inhibit or downtrain is the TFL. Stretching the TFL, doing cross-frictional massage or Graston Technique to the TFL, and using inhibitory taping can all be helpful. The TFL belly is short, but it has a long-lever arm and is a significant internal rotator, especially when the posterior muscles are inhibited.

Here are the keys to an effective stretch of the hip flexors with a bias toward the TFL. The leg you are stretching should be externally rotated; this helps focus on the TFL. It is critical that the patient maintain a posterior pelvic tilt, activating tucking the pelvis underneath them. If they don't, they can sublux their iliosacral joint with this stretch.

One version of the stretch is done standing, if the patient has enough strength, flexibility and stability. Have them stand on the non-involved side with the knee slightly bent, and fully bend the involved leg at the knee. Grab the ankle or foot with the opposite arm, thus externally rotating the involved leg. Activate the abs and glutes to strongly initiate a posterior pelvic tilt. Actively push the involved knee toward the ground inferiorly. The patient should feel a strong stretch in the anterior thigh. There are plenty of variations of this stretch, done prone or side-lying. Use of a strap may help.

The gluteus medius and the small hip external rotators (piriformis, gemelli, etc.) are probably inhibited. You want to retrain them. It may be helpful to do a deep form of soft tissue, such as Graston, or manual deep pressure, as the patient externally rotates and abducts. Pay particular attention to the insertions of the deep lateral rotators into the back of the greater trochanter. This can be best assessed and treated side-lying.

It is a challenge to properly train the patient in home exercises for the hip abductors (gluteus medius). The patient is likely to substitute with the already overactive TFL. In the clam shell and side-lying leg-lift positions, if the patient rotates the pelvis posterior in the transverse plane, they are cheating by lining up the TFL or rectus femoris to help them. Pay close attention to positioning and make sure the gluteus medius is firing, not the TFL.

The other key soft-tissue issue is recognizing that "piriformis" pain - pain or tenderness behind the greater trochanter - does not automatically mean that the piriformis and the other lateral rotators are tight. When the hip tends to internally rotate, theses muscles tend to get stretched out and weak. The pain can be a stretch-strain pattern. This indicates a muscle that is stretched into length and irritated.

Don't stretch it; strengthen it. The posterior hip will feel tight to the patient, but they should not stretch it, because that just reinforces the pattern. That doesn't mean the piriformis doesn't have trigger points. Weak muscles also benefit from soft-tissue work.

We see the psoas as primarily a stabilizer of the hip and lumbar spine. In the hip, its primary function is to pull superior on the femur, sucking the hip up into the joint. It will often need retraining. (I also addressed this in the anterior femoral glide article.)

Finally, don't forget the rest of the core. These folks may need increased core endurance and motor control. Other significant muscles include the hamstrings and the adductors.

The typical medical diagnosis for most posterior hip pain is trochanteric bursitis. I am skeptical about whether the bursa is actually inflamed. In my opinion, the bursa and/or other soft tissues are probably irritated due to the chronic stress strain of the external rotators as they insert into the greater trochanter. I also think the answer is normalizing the biomechanics, rather than starting with a cortisone injection. If deep-tissue work and rehab help this pain pattern, it is probably not a true bursitis, but an insertional tendonopathy or periosteal irritation, secondary to the stretch-strain.

The diagnosis of piriformis syndrome is a strange one to me. The piriformis is clearly a player here, but it is important to understand why. I think "piriformis syndrome" is secondary to hip and SI dysfunction, and that the piriformis is just one player in this symphony.

References

1. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby, 2002.
2. Heller M. "Anterior Femoral Glide Syndrome."  Dynamic Chiropractic, Jan. 1, 2009.
3. Heller M. "The Hip Joint: Myofascial and Joint Patterns."  Dynamic Chiropractic, May 7, 2007.

Still More on the Sacroiliac: Basic Principles and Two More Sacral Lesions

By Marc Heller, DC

Yes, I am writing one more article on the pelvis, the third one in this series. After 30 years of practice, I still find chronic lower back and pelvic pain fascinating and challenging. We'll start with an overview of what you, the doctor, needs to address to stabilize the pelvis.

Self-Correction Exercises

We'll start with self-correction for the patient. I try to teach the patient self-mobilization exercises for any chronic joint problem. This is relevant and useful even when there is a hypermobility component to the SI problem. There are two self-mobilizations that I teach for the SI (if you have another, let me know). For an ilium that continually slips anterior-superior, as seen from the front (evaluate the ASIS levels), Don Tigny's basic SI self correction seems to work pretty well. See my article describing this ["Sacroiliac Joint Correction: A Different Model," Dec. 17, 2005] for details. The patient brings the bent leg on the affected side, the anterior-superior side, into full flexion, then resists pushing the bent leg into extension, then uses their arms to passively bring it back into full flexion. This sagittally rotates the ilium. Tigny would have the patient do this on both sides; I tend to find it useful mostly on the AS side.

If the problem side, the symptomatic side, is the PI side, I like home SOT blocking as a self-corrective manuever. A block or wedge (which can be a shoe stuffed with a sock for home use) is placed horizontally under the iliac crest on the PI side, and obliquely downward under the greater trochanter on the AS side. Instruct the patient to lie supine on these blocks for 3-5 minutes, twice a day. It should feel good to them.

SI (Trochanter) Belts

I love SI belts, also known as trochanter belts. They are simple, usually well-tolerated and make a difference for the patient. I use them when it is obvious to me that hypermobility is part of the problem. I like to pre-test to see if they are likely to be effective. If the patient has pain while bending forward, I will put the belt on them and see if the pain reduces. If the patient has pain while turning over in bed, I will have them do the same motion on the table, and then belt them and have them repeat the motion that previously hurt.

It is useful to have a clear indicator of when to use an SI belt. Sometimes these tests are clear; sometimes not. I prefer that these belts be used relatively short term, about two months; after that, the patient should wean themselves off the belt. Once they are done with daily use, I tell the patient to leave the belt in the glove compartment of their car, as one of the challenges for a chronic SI is a prolonged sitting environment. They may also need the belt when they garden, lift or twist.

Muscle Function

Another critical issue is muscle function. Most patients with an unstable SI will develop unilateral gluteal atrophy. If you just palpate the glutes, one side will feel gushy, the normal side more firm. This needs to be rehabbed. It's the usual catch-22 of chronic back pain: The pain and dysfunction creates muscular inhibition, and somehow you need to solve both the muscular and pain patterns simultaneously. I have moved toward a more functional approach to gluteal training using more weight-bearing exercises, such as functional reach and angle lunges.

The other key muscular pattern may be familiar to you, as it occurs in all chronic back pain. The deep, more medial spinal muscles, which include the multifidi, become inhibited. The more superficial, more lateral muscles, the erector spinae group, become overactive. How does this affect the SI? The multifidi attach to the sacrum, so as they extend the spine, they pull the sacrum into nutation, into a sacral-base flexion. This is inherently stabilizing to the SI. The erector spinae attach to the ilium, so as they fire, the extension is created at the ilium, pulling the ilium anterior, the inherently unstable position of the SI joint. So, rehab the multifidi and downtrain the erectors; more easily said than done.

Ligaments and Tendons

Ligaments and tendons are usually dysfunctional in a chronic sacroiliac. (Again, reference one of my previous articles, "Sacroiliac Revisited: The Importance of Ligamentous Integrity," July 2, 2005; I am always pleased when an article I wrote five years earlier is still relevant and useful.) First, you have to find them. Fortunately, a simple palpation for tenderness is usually diagnostic. I have added the sacrospinous ligament (both at its origin and insertion) to my search pattern since the 2010 Interdisciplinary World Congress on Low Back and Pelvic Pain (which I reviewed in the Jan. 15, 2011 issue). The tenderness over the ligaments may resolve from the adjustment, may resolve from normalizing hip motion or may remain. Graston Technique or manual cross-friction are often effective for chronic tendonosis or ligamentous insertional enosopathy. If the patient is not responding to Graston, you may have better results with some form of myofacial release.

Another useful technique for hot spots at a ligamentous or tendon insertion is counterstrain or positional release. I use this when the hot spot is very discrete and exquisitely tender. It is simple; think of slacking and holding. Find a position that shortens and slacks the involved tendon and substantially decreases the tenderness to palpation. Hold it for 120 seconds.

Lighten up your digital pressure on the tender point once you have found the correct position. Your hand on the hot spot is not doing the work; the positioning is doing the work. The best theory I have heard on why this works: A sudden strain pattern set up an aberrant firing pattern in a muscle spindle or a golgi tendon organ, and you are just resetting this neurological pattern. If the ligaments remain tender despite your best efforts, the patient may be a candidate for proliferant injections.

Don't forget the lower extremity. My favorite most-missed pattern is the hip that lacks internal rotation. If the hip doesn't move properly, the SI takes on extra load. Don't forget the foot and ankle; pronation destabilizes the whole of the lower extremity, and a supinator tends to be rigid and lack shock absorption.

Who else is going to properly manage chronic joint pain? It is your job, doctor. Don't just pop and pray. Really look at your chronic patients and individualize the plan for them.

Two More Sacral-Side Lesions

There are two additional sacral-side-of-the-SI-joint lesions that are described in muscle energy. These are less common than anterior or posterior torsions, but still can be significant. (See my videos on these at www.youtube.com/marchellerdc. I am also going to post a table, titled Sacral Corrections, on my Web site for your use. I utilize the table in my treatment room to help me differentiate the sacral lesions.

In review, both anterior and posterior sacral torsions show restriction on the sacral side of the joint, and the restricted side is prominent or superficial. On that same side, the lower sacrum, the inferior lateral angle, is prominent (posterior) or inferior. See my previous article ["The Sacral Side of the SI Joint," Dec. 16, 2010] for a review of these first two sacral lesions.

Our next sacral lesion is a unilateral nutation, meaning the involved side has nodded forward into sacral-base flexion. This is also called a side-bent sacrum, as the sacrum has dropped inferior in the frontal plane on the involved side. This is the only one of our four sacral lesions in which the sacral base is deep on the restricted side, as this is a unilateral nutation. This usually has a traumatic origin.

The correction is direct and relatively simple. Lift the patient's pelvis and place a pillow under it to induce lumbosacral flexion, as you are trying to lift the stuck anterior unilateral sacrum.

The other keys can be remembered as I, I, I: internally rotate the hip, to distract the joint. Contact the inferior part of the sacrum. Do the correction on the inspiration phase of breathing. As the patient breathes in, push the involved sacrum from below in a superior direction. As the patient breathes out, your other hand pushes the opposite, more superficial side of the sacral base inferiorly, while continuing to hold the superior pressure on the involved side of the lower sacrum.

The final lesion is a counternutated sacrum. In this one, the involved side of the sacral base has gone posterior, has counternutated or extended. This is the only lesion in which the ILA, the inferior portion of the sacrum, has come superior on the involved or restricted side.

I like this correction; it's simple and clean. Stand on the opposite side from the sacral restriction. (The keys here can be remembered as E, E, E.) Have the patient propped on their elbows, inducing extension. Place the leg into external rotation. Perform the correction duringexpiration. You are going to grab the ASIS and anterior pelvis on the opposite side from where you are standing. You are pulling it toward yourself; call it anterior to posterior. Use the heel of your hand to push the involved sacral base from posterior to anterior, directly toward the table. During the inspiratory phase, just hold your pressure. Repeat 3-4 times. You will  really feel the motion induced during this correction.

If you wrap your brain around all of these differentials, you'll see why the stork test is so critical. [See "Sacroiliac Mobilization, Part 1,"  Nov. 4, 2010 issue]. You need to know which side of the sacrum is restricted. Once you know that, the rest of the pieces can be teased out. Chronic sacroiliacs can be very challenging; having the right tools can improve your results and your patients' lives.

The Sacral Side of the SI Joint: Correcting Anterior and Posterior Torsions

By Marc Heller, DC

Editor's note: This is the second in a series of three articles on SI mobilization. The first article appeared in the Nov. 4 issue.

I have a memory, now at least 32 years old, of Dr. Hogan, my technique teacher at National. I was a "know it all" back then, but for some reason I paid attention when he said: "Adjust the sacrum, not the ilium." I think he was referring to the tendency of the ilial side of the joint to compensate, and the tendency of practitioners to adjust the easily assessed iliosacral joint. You often have to address the sacral side of the joint separately.

I have gone back and forth with using the muscle energy model of the sacroiliac(an osteopathic low-force spinal adjusting technique using post-isometric relaxation) for the past 16 years. In my opinion, the model is a bit cumbersome, the terminology has never really made sense to me, and the palpation system is nothing like the rest of the motion palpation that I use - but despite all these drawbacks, muscle energy seems to address the sacrum more effectively than anything else I have used. Once I started using the stork test again, I realized how many sacral fixations I was missing, and that my previous corrections didn't always correct the fixation. I am once again using this model daily.

Top: Position for correction of left anterior sacral torsion; Bottom:Position for correction of left posterior sacral torsion.I will repeat what I said in the previous article about the sacral side of the SI joint. In the stork or Gillet test, when you are testing the weight-bearing side, you are testing how well the sacrum is moving on the ilium. When the patient lifts their bent right leg as high as they can, we are testing the left-side sacral function. Your left thumb is on the left PSIS and your right thumb is just medial to this, on the sacrum, at the left sacral base at S2 or so. Can your right thumb, on the left upper sacrum, appear to drop inferior as the right bent leg is lifted to end range? If your thumbs appear to move inferior together, the left sacrum is fixated.

The next part, to a chiropractor, will feel like a weird variation on motion palpation. Instead of moving a bone, you are assessing as the patient moves around your hands. Much of this assessment is visual, rather than kinesthetic.

The patient lies prone. If the left sacrum is stuck, I am first assessing the depth of the sacral sulcus, at the sacral base, comparing one side to the other. Using your dominant eye, look directly in the midline, looking down at your thumbs on the sacrum. This is both a visual and a positional palpation finding. In anterior or posterior torsions, the involved side will be more superficial, so the opposite side looks deep. You will also assess the horizontal level at what the osteopaths call the ILA, the inferior lateral angle near the bottom of the sacrum.

Line up your fingers on what feels like the same structure on each side on the lower sacrum. I like to do this twice, once coming more posterior to anterior on the sides of the sacrum, and the other coming up from below. This one is a pretty pure visual test. In either of these torsions, the ILA will be inferior or more prominent (as if it is rotated back) on the fixated side.

What does this osteopathic terminology, sacral torsion, mean? It implies that the sacrum is twisted around an oblique axis. In both cases, both in a left anterior torsion (called left on left; don't even ask me what that means), and in a left posterior torsion (called left on right); the left sacral base palpates and visualizes as posterior. The left ILA is more prominent in both of these lesions. The anterior torsion is considered more of a compensation, as if the gait got stuck at one end of the motion. A descriptive term for this might be sacrum vulgaris or the common sacral dysfunction. It is sometimes described as a problem with piriformis hypertonicity.

The posterior torsion, or stuck posterior pattern, is a more significant fixation, completely restricting any extension motion of the lower lumbar and sacral spine. When you have a posterior torsion, you will often also find a lower lumbar vertebral joint that resists extension and side-bending. A posterior sacral torsion completely locks up the lower back. If it occurs concurrent with an anteriorly rotated ilium, it can be even more problematic.

These patients may present with sciatica, which may be coming from the stuck SI joints rather than from a true disc lesion. Or perhaps the stuck sacrum and lumbars are putting further stress on an already compromised disc. They may not get relief from McKenzie extension, as they cannot extend with ease. Once you correct both the posterior sacral torsion, and the stuck-in-extension lumbar vertebrae, then self-mobilization into extension is likely to be helpful.

Differentiating an Anterior Torsion From a Posterior Torsion

The static palpation findings are the same for an anterior and a posterior torsion. With both, the sacrum is more superficial, more prominent on the fixated side. With both, the ILA is more prominent on the fixated side.

We differentiate them with motion. In the muscle energy model, we use the patient's own motion. The patient lies prone; your thumbs are in the bilateral sacral sulcus. In our example, the left sacral sulcus is more prominent. Now, ask the patient to prop themselves up on their elbows or push up with their arms, leaving the pelvis on the table. They are producing extension in the lower spine. You are watching and feeling what happens at the sacral sulcus. If this extension motion helps correct the sacral unleveling, you are looking at an anterior torsion. If the extension motion either leaves the sacral unleveling unchanged or makes it worse, you are looking at a posterior torsion. As I mentioned, in a posterior sacral torsion, the lumbosacral junction loses all of its ability to extend. You can just spring the lumbosacral junction here; it will be very rigid in a posterior torsion.

Correcting the Sacral Torsions

In the muscle energy model, for any fixation, you first take the patient to the soft end-range in all three directions. You then use post-isometric relaxation, having the patient contract and then relax. As they relax, the fixated joint moves farther into the barrier, freeing up the joint. I suspect that this is the aspect of muscle energy that is least well understood. The trick to doing a good job with the osteopathic styles of low-force adjusting is in the subtlety of finding the end play, and of positioning the patient at the soft end-range of the barrier. It's like a good paint job: all the hard work is in the preparation. There are variations in how these techniques are done. A master of muscle energy makes it look easy, setting it up so the body just seems to correct itself.

Here is how to correct an anterior torsion. The goal is to release the anterior (deep) side - the right side in our example - back into place. In our example, the left side is both fixated and more superficial, so the lesion is a left anterior torsion. The patient lies on their left side with the left arm behind them. Having the left arm behind twists the upper body farther into a left rotation.

Move the patient's right arm and upper body to the end range of that rotation. Bring both of the patient's bent legs off the table, and bring the lumbar spine farther into flexion. As you do this, you palpate the lumbosacral joint and take the legs into enough flexion to begin to open the lumbosacral joint.

Now, have the patient push in a superior direction - toward the ceiling - with both feet for a five count, against your resistance; when they relax, take up the slack on all of the barriers. Repeat two more times. If you have never done this style of muscle energy, you will be surprised by how the barrier seems to soften and recede during this seemingly minimal procedure. Your right hand is monitoring at the lumbosacral junction, but not really doing the correction.

The usual instruction is for the patient to push very gently; most patients will try to push hard. I like to sit on a stool. You are supporting both of the patient's knees on your thighs. I often use a small pillow on my thighs, just for my own comfort. Remember, you are releasing the deep side. As the patient is left-side lying, your focus, at least for a typical chiropractic move, would be on the right side of the involved sacrum. There is no thrust in any muscle energy adjustments. It's all about the positioning and the contract-relax to reset the joint. The hardest part for a typical chiropractor is the absence of pushing or thrusting; just let the correction happen.

Here is how to correct a posterior torsion. I've seen several variations on this move. (There is a truly elegant YouTube video of another variation on this correction - which the presenter calls a left on right, the osteopathic terminology for the same posterior torsion lesion - atwww.youtube.com/watch?v=_tYiv4cSzbs&feature=related. The correction I commonly use for a left posterior torsion involves the patient right-side lying with the left side up, both arms in front. It starts out like a typical chiropractic side-posture move.

Roll the patient's left shoulder back, taking out the slack of the left rotation. Then bring the bent patient's upper leg into about 90 degrees of flexion. Make sure the patient's lower leg stays straight and move it slightly backward into slight extension on the table. The fingers of my right hand are monitoring the left sacrum, but not really actively doing any correction.

The contract relax can be done in two ways in these techniques. In the first version, the patient pushes their bent knee upward toward the ceiling against the isometric resistance of your left hand for a five count. They then relax, and you take up the slack on all of the barriers, especially focused on rotation, bringing the bent leg toward the floor. Repeat two times. Another version uses a scissors type of movement. In this one, the patient isometrically extends or straightens the bent left leg against your left thigh's resistance, and flexes the straight right leg against your right thigh. As they relax, you move the lower leg farther into extension and the upper leg farther into flexion. In either version, you'll feel the left side of the sacrum release.

I know that the written word is not always the ideal way to teach technique. Atwww.youtube.com/marchellerdc, I've posted videos of these two techniques. I also know one article is not enough to learn a new model or new technique. Some  of you may start using the Gillet/stork test more consistently, and finding out whether your typical sacral techniques are working to release the sacrum. Others may want to further pursue a deeper understanding of muscle energy methods.

Resources

1. Comerford M. Mobilization of the Sacroiliac Joint (class), June 2008, Kinetic Control.
2. Whyte-Ferguson L. Clinical Mastery in the Treatment of Myofascial Pain. Lippincott, Williams and Wilkins, 2005.
3. Greenman's Principles of Manual Medicine, 4th edition. Lippincott, Williams and Wilkins, 2011. An earlier edition of this was my bible for muscle energy technique