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MET IN SI JOINT DYSFUNCTION
DR.POOJA JOSHI

 Piriformis Function
The piriformis
muscle functions to
support and assist
the sacrospinous
ligament in
restoring the
sacrum to its resting
position

 The sacral origin of
the gluteus
maximus serves to
assist and support
the function of the
sacrotuberous
ligament in bringing
the distal sacrum
anteriorly and
laterally

TESTS FOR ILA POSITIONS
1.PRONELYING
2.SPHINX POSITION
3.HYPERSPHINX POSITION
4.STANDING

 Backward torsion shows maximum
asymmetry in the Sphinx position.
 Forward torsioned sacrum becomes
symmetrical if the Sphinx position is extreme
enough
 If the sacral sulcus of one side is deeper, and
the sacral ILA of that same side is more
inferior and posterior than the opposite ILA,
there is unilaterally flexed sacrum on that
side

 If the deeper sulcus is on one side and the
prominent ILA is on the other side, there is
sacral torsion toward the prominent ILA side

Tests
 1.forward flexion test
 2. seated flexion test
 3.supine SLR test
 4.prone extension test

 1.forward flexion tests:
 To test forward flexion, the patient stands
weight equally distributed on both legs.
 The examiner sits behind the patient and
palpates both PSIS
 The patient is asked to bend forward and
symmetry of movement of the PSIS
superiorly noted

Sacrum torsioned left on the
left oblique axis (Left-on-
Left)
 All left torsions should
have a fifth lumbar
rotated right and
sidebent left
 Sacrum rotated left
 Side bend- right
 sulcus – deeper on
right
 ILA – inferior on left

bony positions of a Left-on-
Right
backward torsioned sacrum.

bony positions of a Right-on-
Left
backward torsioned sacrum.

 The ILA and sulcus depth findings look the same
in forward torsioned as in backward torsioned
sacrum to the left
 Without the sphinx test it is not possible to tell
whether asymmetric landmark (ILA or sulcus)
displacement is forward on one side or
backward on the other.
 Forward torsions straighten in the sphinx
position and worsen with forward trunk
bending. Backward torsions get worse in the
sphinx position and straighten with forward
trunk bending.

1.Treatment for unilaterally
flexed sacrum
 Loosed pack position-15
degree abduction
 Medial rotation - opens
up the posterior rim of
the sacroiliac joint
 creating an opportunity
for the sacral base to
move backward
 a movement which
spreads the posterior
superior iliac spines.

 The index finger continues to palpate the sacral
sulcus while the other hand applies a ventral
springing pressure to the ILA on the side of the lesion
with l-2 kilograms of force
 varying the angle of pressure slightly until the sulcus
palpation indicates that the direction of force is the
direction of greatest freedom of sacral movement

Treatment of a Resistant
Unilaterally Flexed Sacrum
 loose-pack
 internally rotated position by
bending the knee to 90
degrees and moving the foot
laterally
 step-inhalation
 have the patient hold the
breath and isometrically
externally rotate the femur
against your unyielding
resistance

Self Treatment for Recurrent
Unilaterally Flexed Sacrum
 The patient sits with the teet
flat on the floor
 knees shoulder width apart.
After bending forward,
attempting to get the elbows
between the feet
 the patient takes 3 deep
breaths. After each breath is
exhaled completely the
patient attempts to increase
the flexion
 This attempt may be helped
by pulling on the chair legs
with the hands

Treatment for Sacral Torsion
Dysfunction
 1.forward
 2.backward

Procedure Protocol for Treatment
of the Forward Torsioned Sacrum
(Left-on-Left)
 The hips and knees are flexed
to 90 degrees.
 The knees are together and
about 6 inches ( 15 Cm.)
beyond the edge of the table.
 The trunk is rotated so that
the chest approximates the
table surface.
 The arm lying upward hangs
over the table edge; the other
arm rests on the table behind
the back.

 Operator holds the
patient's right shoulder
forward, maintaining
trunk left rotation, and
lowers the patient's feet
several inches, usually
below table level
 This has the effect of
externally rotating the
right (top) thigh and
internally rotating the
left.

 This has the effect of
externally rotating the
right (top) thigh and
internally rotating the
left.
 Hold the feet at the
comfortable limit of
thigh rotations, and ask
the patient to push the
feet up against your
unyielding resistance
(toward the ceiling)

forward torsioned sacral
dysfunction with the therapist
seated position
 useful tor treating
the larger, older, or
obese patient
because it provides
better support for
the patient's legs.

 The patient sits on a firm chair
or low stool with the feet on
the floor, ankles and knees
together.
 Ask the patient to "slump”
 The patient puts both hands to
the side of the lap.
 corresponding to the side of
the oblique axis. Say to the
patient, "Breathe in and out
and reach your forward hand
toward the floor."
 Use your hand to hold the
shoulder back, preventing
trunk flexion.

Treatment Techniques for
Backward Torsioned Sacrum
 a patient having a "Left-on-
Right" (lett torsion of the
right oblique axis) lesion
 would lie on the right side.
 With your other hand move
the bottom leg posteriorly,
hyperextending that hip
until movement is felt at the
lumbosacral junction.
 The leg will remain in this
extended position
throughout the rest of the
procedure.You may remove
your hand from the leg.

 Maintaining trunk rotation, and pelvic alignment,
bring the patient's top foot off the table by
straightening the knee without flexing the hip.
 Maintaining pelvic alignment, place your hand
which has been palpating the lumbo-sacral junction
on the foot, leg, or knee to resist abduction of the
top leg

 Resist the abduction and move the leg out of
the couch

Rotated Innominate Dysfunctions

 The patient lies on the noninvolved side,
lesioned innominate up
 The leg on the involved side is positioned by
flexing the hip and knee of that side to about
90 degrees.
 the patient attempt to adduct the femur
against your unyielding resistance and then
relax

 You resist the upward push of the knee with
your hand on the lateral aspect of the knee
instruct the patient to abduct the hip
 hip flexion should be sufficiently increased to
permit you to place your arm between the
knee and the patient's ribs
 Ask the patient to extend that hip as you
resist the effort. "Push your foot against me."

 The patient is prone, lying
close to the edge on your side
of the table, and should be
able to hang the leg down off
the table.
 The knee of the hanging leg is
flexed to approximately 90
degrees, so that the foot can
be placed on your nearer knee
 patient attempt to extend that
hip as you resist the effort.
"Push your foot back against
me

"Hard Way Shoe Tie"
 Put your right foot on
a chair or low stool.
 Try to "tie your left
shoe laces" with your
left knee straight.
 The patient stands
with the right foot in
the seat of a chair,
and then reaches
both hands toward
the left foot.
 Staying in this
maximum flexed
position

TREATMENT OF POSTERIOR
INNOMINATE
 The patient is
prone, preferably
on a very low table
 You stand at the
side of the table
opposite to the
lesion.
 Your hand grasps
the anterior aspect
of the knee on the
side to be treated

 with the thenar eminence contacting the
posterior iliac crest on its most superior lateral
aspect
 Lift the leg, extending the hip, by keeping your
elbow straight and leaning your body toward the
head of the table.
 If the knee bends, ask the patient to relax the leg
and let the weight of the foot keep the knee
straight.
 Maintaining the extended position described
above, have the patient attempt to flex that hip,
as you resist the effort

 The top leg is extended and
slightly abducted at the hip
 so that it clears the other
lower extremity.This is best
accomplished by supporting
the flexed knee with your
hand and arm and stepping
back.
 Maintaining the position
have the patient attempt to
flex the hip as you resist the
effort.
 Have the patient relax. "Pull
your knee forward."

REFERENCES :
 Greenman, P.E.,Principle of mannual
medicine.
 Fred l mitcheel , JR.p.kai galen mitcheel,the
muscle energy mannual
 Leon chaitow, muscle energy
technique,churchill livingstone

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Met in si joint dysfunction

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