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November 16, 2016
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Technical Report
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http://www.researchgate.com
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DOI: 10.13140/RG.2.2.29972.50561
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The Sacral X Axes
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Location, Structure, Movement, Parallel Kinetic Ligamentous Loading, Function, Biotensegrity Technology and Pathology. The essential pieces of the low back pain puzzle.
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Richard L. DonTigny, PT Independent researcher 81 North Shore Drive #10 Belgrade, MT 59714 406-219-3416
[email protected]
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I am the sole author. This is my discovery, my research, my illustrations and my biomechanics. The manuscript submitted does not contain information about medical devices or drugs. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. This represents over 50 years of investigation and 8,000 patients in the area of idiopathic low back pain. © DonTigny
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Key Words
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Sacral X axes, force couples, balanced ligaments, pelvic biomechanics, biotensegrity of gait, sacroiliac pathology, immediate relief of common low back pain.
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Abstract
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In the last century much research was accomplished on the pelvis yet the pelvis remains an enigma. Movement was located and measured, but not specified, comprehended or described. An oblique axis was suspected but not identified. Some function of the pelvis is suspected, but it has not been described or understood. Many practitioners suspect the pelvis to be the source of common low back pain, but just as many practitioners believe this not to be true.
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During normal gait an initial unilateral posterior innominate rotation on the side of the first step causes the ilial tuberosity to push caudad directly on the lateral sacrum causing a lateral sacral flexion with rotation. The trunk is caused to counter rotate thus decreasing loading forces to the femoral head. When loading is shifted to the contra lateral side on the second step the weight shift takes place with biotensegrity mechanics. Movement is through balanced, interchangeable, parallel, kinetically loaded ligaments that create interactive force couples. None of this was possible to determine without the sacral x axes. This is all way beyond conventional biomechanics.
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Acute and chronic back pain is essentially all caused from an anterior innominate rotation (lifting, bending lowering, shoveling, sweeping, pregnancy or a postural forward head) that causes the innominates to rotate cephalad and laterally at the PIIS. This is a measurable movement that puts a vertical shear on the lateral axis points and separates the sacral origins of both the gluteus maximus and the piriformis from their ilial origins resulting pain in the buttocks, piriformis syndrome and sciatica. Dysfunction is all initiated at the sacral x axes. This is corrected effectively simply with a manual bilateral posterior innominate rotation that reverses all symptoms leaving the patient free of pain. 408 words
Ten years ago two separate points were located that looked like they could function as bony transverse sacral X axes providing the pelvis was symmetrical, however, if and when the pelvis is asymmetrical each point could also function with a related pelvic point and act as an oblique axis. The resting pelvis is unmoving and almost immobile, however, the erect and loaded pelvis is dynamic and filled with kinetic energy. Primary sacral loading is on the posterior interosseous ligaments and serve to suspend the sacrum. The primary loading initiates a secondary loading on the sacrotuberous ligaments that balances the primary loading. These two sets of balanced ligaments create two sets of interactive force couples and a trigger for biotensegrity.
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Introduction
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The complexity of sacral mechanics is awesome. Many researchers have tried to define, measure and describe movement and function in this joint. Some of the things that have confused many are that movement in the weight loaded pelvis is entirely different than in the non-weight bearing pelvis, that loading of the sacrum is vastly different than loading of the innominates and that movement at the sacroiliac joint (SIJ) is completely different than movement at any other joint. A possible oblique axis has been suspected, but its location has not been identified. (1)
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In 2007 two rather obscure and commonly overlooked transverse sacral X axes were discovered at the posterior aspect of sacral S3.(2) These axes work together as a common transverse axis when both innominates are symmetrical or individually as oblique axes when the innominates are asymmetrical or rotating in opposite directions. (2) Analysis of movement and function has been relatively straight forward and somewhat simplistic once these axes were identified and involves structure, kinetic loading, balanced ligaments, force couples, inter-acting oblique force couples and a trigger for biotensegrity.
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Normal gait is initiated when one leg is lifted and that knee is flexed resulting in hip flexion and a posterior innominate rotation on that side. The ilial tuberosity pushes down on the posterior-lateral sacrum resulting in lateral sacral flexion with rotation that increases balanced kinetic ligamentous tension on the side of loading. Tension and loading decreases after impact and innominate rotation and lateral sacral flexion are reversed at single leg support resulting in a palpable sacrum moving obliquely laterally and rotating with each step. Illustrations and x-rays are used to help locate the sacral X axes, to demonstrate balanced ligamentous loading and to illustrate their function as biotensegrity mechanics during normal gait. This has not been previously possible to describe without the critical sacral X axes.
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Figure 1. The transverse sacral loading axis (The X axis). Note the angulation of the sacroiliac joints, how loading of the sacrum will tend to open this joint and how this is prevented from acting as the keystone of an arch. Note how the iliac tuberosities at the PSIS overlie the sacrum, lock the sacrum in nutation and prevent any movement in posterior rotation of the innominates on the sacrum. All dysfunctional movement of the innominates must be in anterior rotation. To demonstrate dysfunctional movement on x-ray, take the PIIS from this angle. Courtesy of the Journal of Prolotherapy © DonTigny
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Structure The sacral X axes lie snuggly and unobtrusive just caudad and medial to the ilial tuberosities at sacral S3 on each side. (Figure 1)
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Vukicevic found that in normal standing, the sacroiliac joints can withstand a wide range of loading without pelvic or sacral deformation even after the elimination of the sacrotuberous and sacrospinous ligaments.(3) The joint surfaces do not approximate with this loading, however, these joints become profoundly unstable after the removal of the posterior interosseous ligaments. Without ligamentous restrictions, the super-incumbent weight causes the sacrum to tilt ventrally, essentially unimpeded by structure. When there are no ligamentous restrictions, the structure of the joint allows it to open.
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Parallel Kinetic Ligamentous Loading When loading the super-incumbent weight in moving from a supine to an erect posture, the posterior interosseous ligaments (F1) are loaded first, which causes the S1 sacral segments above S3 to move slightly anteriorly and downward. The sacrum inclines ventrally on the sacral X axis with this loading causing a simultaneous secondary loading dorsally on the sacrotuberous ligaments caudal to S3 (F2). The secondary sacral loading posterior and caudal to S3 balances the primary sacral loading at S1. (F1 = F2) The primary loading force is constant after loading. The secondary loading force is dependent upon, is directly related to, must equal and thus balance the primary loading force.(2,4,5) (Figure 2)
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Figure 2. Primary sacral loading (SL 1) occurs on the posterior interosseous ligaments with an instantaneous; equal secondary sacral loading (SL2) of the sacrotuberous ligaments in the opposite direction. Note the location of the sacral axis and the angle of the SIJ. Without the supporting posterior interosseous ligaments the sacrum would tend to fall away from the innominates. Courtesy of the Journal of Prolotherapy © DonTigny
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The secondary loading forces below S3 (F2) must equal, but cannot exceed the primary loading 1 1 2 1 2 forces at S1 (F ). Therefore F = F . Therefore F – F = 0. With normal loading, force closure equals 0. With overloading (X Kg) F1 + X = F2 + X. Therefore (F1 + X) – (F2 + X) = 0. Force closure must still equal 0. (2,4,5) (Figure 3)
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Figure 3. The lumbar lordosis is increased with the primary sacral loading, as is the lumbosacral angle, but because the line of gravity is posterior to the acetabular axis, loading of the sacrum causes a simultaneous, sequential, secondary loading of the pelvis resulting in a posterior pelvic rotation on the acetabular axis. The secondary loading of the pelvis further balances the ligaments, decreases the lordosis and decreases the lumbosacral angle. Courtesy of the Journal of Prolotherapy © DonTigny
Thus the primary loading force (F1) and the secondary loading force (F2) are always in balance. Any increase in weight carrying will increase both primary and secondary loading equally. Thus the closing force at the sacroiliac joints will be essentially nil. Note also that the sacrotuberous ligaments are helical. The helical coils improve dynamics, allow for greater elasticity, increased movement and a greater storage of kinetic energy during normal ambulation Opposing forces created when these ligaments are loaded create transient, multiple, interchangeable force couples. The moments created by the force couples create force-dependent transverse and oblique axes of rotation for the SIJs when the sacrum is loaded. The secondary loading caudal to S3 must be strong enough to equal the primary sacral loading at S1 in order to stabilize the ilial convexities in the sacral concavities. These force couples modify, absorb and redirect forces such as linear and angular acceleration and deceleration, linear and angular momentum, impact loading and unloading and others. Force couples help to enhance function, preserve the systems, and prevent injury. If the sacroiliac ligaments were removed and the subject moved from supine to erect and loaded the sacrum, the sacrum will continue to incline ventrally. It will move ventrally at S1 and because of the ilial tuberosity superior to S3, the caudal sacrum will move dorsally on the sacral X axis. If it were not for the ligamentous restrictions, the sacroiliac joints could not sustain weight loading. This is totally dependent upon the line of gravity being posterior to the acetabular axis causing a posterior innominate rotation, which further balances kinetic tension on the posterior interosseous and sacrotuberous ligaments. (Figure 3)
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Movement
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Function
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The innominate is forced into asymmetry and to flex laterally right or left with posterior rotation, which initiates transient, alternating, oblique force couples. The sacrum moves obliquely back and forth with the alternate changes in posterior innominate rotation. The transverse S3 sacral X axis is functional only in the position of the symmetrical pelvis at swing- through at the mid-step position when the loaded
Sacral movement that occurs during loading and unloading of the superincumbent weight is not the same as the movement that occurs after the sacrum is loaded. After loading, essentially no movement occurs on a transverse axis on the symmetrical pelvis even though ligamentous tension will vary. Resting kinetic tension on both the posterior interosseous and sacrotuberous ligaments is relatively high and balanced in supine, prone or cadaver. (6) Posterior rotation of both symmetrical innominates will increase tension on both the posterior interosseous and sacrotuberous ligaments, decrease the lumbosacral angle, decrease the lumbar lordosis and decrease shear at L5-S1. The SIJs are essentially non-weight bearing joints with a balanced loading. Once the ligaments are loaded and balanced, loading may be increased without causing further movement in the SIJ because all loading is balanced and interdependent. Movement of the loaded sacrum occurs as a consequence of innominate movement. The axes for anterior and posterior rotation of the innominate bones on the asymmetric pelvis are at the pubic symphysis. (7) Stevens described lateral sacral flexion with rotation and identified asymmetric movement in symptomatic patients that was reversible with manual correction resulting in restoration of normal motion. (8) Greenman noted that alternate anterior and posterior innominate rotation occurs between the innominates and the sacrum on some posterior axis, but did not identify that axis. (1) Schmidt noted significant angular movement at the SIJs, but did not describe the movement of the sacrum in the change from the left long straddle position to the right. (9)
Some consensus was reached when several researchers found that the structure of the SIJ was such that the sacrum hangs suspended from the ilia by the dense posterior interosseous ligaments and when loaded with the superincumbent weight hangs more deeply between the ilia. This is the reverse of a keystone. (10, 11, 12, 13) Not reported or not known at that time was that this loading was superior and anterior to an obscure and undescribed sacral X axis. An axis for asymmetric rotation of the innominates is at the pubic symphysis while symmetric rotation of the innominate bones is on axes through the acetabula. (2, 4, 5) Both Greenman (1) and Vleeming (14) noted that during the swing phase of the right leg, the right innominate rotates posteriorly relative to the sacrum. Primary sacral loading on the sacral X axis increases lordosis, increases the lumbosacral angle and causes the joint to separate. Primary pelvic loading with posterior pelvic rotation decreases lordosis, decreases the lumbosacral angle and balances the kinetic ligamentous loading. This prepares the pelvis for dynamic movement. From relaxed standing the first movement in normal gait is to flex the knee initiating posterior rotation of that innominate bone to create a pelvic asymmetry. (1) Posterior innominate rotation of the working innominate moving on an axis through the pubic symphysis depresses the ilial tuberosity down on the posterior-lateral surface of the sacrum causing a lateral sacral flexion. (1) Lateral sacral flexion creates an oblique sacral axis with an oblique force couple from S3 on the side of loading to S1 on the off- loaded side and the sacrum rotates toward that side and functions to decrease loading on the femoral head. (Figures 4-5)
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force couple immediately shifts to the alternate, unloaded side. At heel strike the sacrum is rotating anteriorly at S1 on the off-loaded side and posteriorly at S3 on the side of loading, moving on S3-S1 oblique axis. (Figures 4-5) Excess tension caused by loading forces on the oblique force couple increasing posterior innominate rotation is accommodated in the helical sacrotuberous ligaments. Forces decrease after loading and oblique force couples reverse instantly at mid-step when the pelvis is briefly symmetrical and posterior innominate rotation is initiated on the contra lateral side. This is a four-bar biotensegrity movement and is driven by tensioned ligaments. (www.biotensegrity.com)
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Figure 4. From the symmetrical mid-step position, the ilial tuberosity on the innominate on the loading (right) side flexes to create asymmetry and rotates the sacrum on an oblique axis. Kinetic forces in the ligaments increase until impact and then reverse and decrease till mid step when the pelvis is again symmetrical. The unloading (left) side begins to anteriorly rotate and decelerate the loading (right) side. © DonTigny
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Figure 5. At impact on the left, the right (trailing leg) innominate begins posterior rotation at knee flexion and lift off. At single leg support the right (trailing leg) passes the mid line and the pelvis is momentarily symmetrical and moves to asymmetry as the kinetic forces and posterior rotation increase. The loading (left side) innominate flexes and rotates the sacrum toward the left as the kinetic forces increase until impact. The sacrum oscillates once with each impact, twice with each stride. © DonTigny
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Figure 6. X-rays taken from the front of an oblique pelvis in the long straddle position with counter rotation and with loading to the right and to the left. Note the location of the transverse sacral loading axis and the transient oblique axis. Note the posterior rotation of the PSIS and the angle of the sacrum. Courtesy of the Journal of Prolotherapy © DonTigny
The motions can be demonstrated on x-ray with the x-ray at the front of the oblique pelvis in the long straddle position. (Figure 6) This system of movement is commonly overlooked probably because of its obscurity, size and complexity. There is a vast variance in this movement system dependent on the individual length and speed of stride, variance in pelvic flexibility, posture and ambulatory pattern. Functional asymmetric posterior innominate rotation is essential to trigger biotensegrity mechanics. The SIJs function as interdependent, self-compensating force couples with variable, force-dependent, transverse and oblique axes of rotation. This biotensegrity function is palpable with a subject on a treadmill. With a hand on each side of the sacrum, place the tip of each index finger immediately caudad to each ilial tuberosity and the tip of each thumb on each side of the coccyx. Have the patient ambulate with a long straddle stride and the pelvis moving oblique to the line of travel. The tip of the coccyx will flex laterally back and forth, crossing the midline with each step.
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Sturesson’s research
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Dysfunction on the sacral X axes
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As normal function of the sacrum involves transient oblique axes across the sacrum so may dysfunction. Manual tests can give the impression of dysfunction in anterior or posterior dysfunction or combinations thereof; however, because of the proximity of the innominates to the sacrum at the ilial tuberosities, a dysfunction in posterior rotation is not possible. Dysfunction at the sacral axis must always be treated with a manual correction in posterior innominate rotation. (2,4,5)
About the only agreement about the pelvis and low back pain among researchers has been a general acceptance of Sturesson’s work. (15, 16) Sturesson x-rayed small titanium balls implanted in the pelvis, used an XYZ axis at the anterior point of the sacral plateau and made precise measurements in various positions. His method was well thought out, extremely accurate, has been used on over 4,000 patients. He concluded that range of motion in the pelvis is extremely limited in the long straddle position. In retrospect the choice of placement for Sturesson’s XYZ axis, of necessity, was arbitrary, inappropriate and should have been at the bony transverse sacral X axes and each oblique X axis. Measurements made on an inappropriate XYZ axis have led to inappropriate interpretation, inappropriate research, inappropriate results and inappropriate treatment. When Sturesson measured movement in the long straddle position he had the pelvis blocked to the front, which is the position of symmetry the pelvis assumes during normal gait in the single support phase. As a result his measurements of pelvic movement in the long straddle position were all made on subjects placed in the position of a symmetrical pelvis. The lack of knowledge of the sacral X axes, their location, obscurity, movement, function and possible dysfunction has stalled research in the pelvis. The transverse sacral X axes and the sacral oblique axes on each side are more accurate and telling locations than the XYZ axis at the sacral plateau used by Sturesson (15, 16). The discovery of these axes has allowed for the discovery of balanced ligaments, force couples, normal gait and biotensegrity.
These few references and comments are offered as an overview to help researchers comprehend the complexity of dysfunction caused by forces in anterior innominate rotation on the sacral X axis. (Figure 7) Inclusion of the critical sacral X axis is essential to the evaluation and management of dysfunction of the sacroiliac joint (SIJD). Many articles on non-specific back pain have reported no changes with exercises, but non-specific is non-scientific. You must treat the anterior innominate rotation on the sacral X axis.
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Figure 7. Note the apparent subluxation in anterior innominate rotation at the left end of the sacral X axis. Anterior innominate rotation causes an alteration in acetabular location making the legs appear longer. A manual posterior innominate rotation on each side will cause each leg to shorten and each PSIS to move caudad (36). Continue until the leg length no longer shortens and relief will be immediate. (Courtesy of Mitoshi Fukushima MD PhD, Fukushima Orthopaedic Clinic, 13-9, 1-choume, Kairouen, Saeki-ku, 7315135 Hiroshima-shi, Japan.
When the balanced ligament position is released with a force in anterior innominate rotation it will result in a vertical shear of ilial S3 on the sacral S3 segment at the PIIS. (Figure 1 and Figure 8) This painful point is always present with SIJD, but is commonly overlooked. The PIIS is immediately lateral, caudal and deep to the PSIS at the juncture between the ilial and the sacral origins of the piriformis and the gluteus maximus. This is the cause of piriformis syndrome. The sacral origin of the piriformis is separated from its ilial origin at the superior margin of the greater sciatic notch. The sacral origin of the gluteus maximus is also separated from its ilial origin on a line from just caudal to the PSIS, across the buttock, into the trochanter and down the tensor fascia lata into the lateral knee. Simply by identifying this primary painful point at the PIIS the practitioner can make a positive diagnosis of SIJD (4, 5).
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Figure 8. When leaning forward to lift, the sacral origin of the gluteus maximus and the sacral origin of the piriformis stabilize the sacrum. The dysfunction in anterior innominate rotation creates a vertical shear that causes the sacral origins of the gluteus maximus to separate from their ilial origins on a painful palpable line across the buttock to the trochanter and from there to the lateral capsule of the knee. Shear on the ilial origin of the piriformis can cause piriformis syndrome and sciatica. © by DonTigny
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Robinson et al noted that Manipulation of the lower back and pelvic region has been found to improve the symmetry of gait after treatment. (17) Bernard and Fortin each found that the consideration of SIJD as a cause of non- specific back pain has greatly improved their ability to diagnose and treat nonspecific back pain. (18, 19) Ducroquet et al noted a decrease of pelvic rotation in the horizontal plane in patients with SIJD. (20) Grieve found that sacroiliac strains sometimes follow gynecological and obstetrical operations. (21) Calguneri found ligamentous laxity to be a factor in back pain and accompanies pregnancy in the last trimester and to a lesser degree during menstruation and menopause. (22) Grieve found that movement abnormalities of the SIJs and pubic joints are a common cause of persistent postpartum pain, and simple mobilizing techniques localized to the SIJs are very effective in alleviating this pain. (23) Sunderland and Bradley found that an anterior and downward rotation of the innominates on the sacrum may stretch the spinal nerve roots, which in turn may cause neurological changes or lancinating pain. (24) Abdominal pain at Baer’s point is not uncommon. This point is on a line from the umbilicus to the anterior superior iliac spine, two inches (5 cm) from the umbilicus.(25, 26, 27) I had a patient who suffered from abdominal pain at Baer’s point and LBP for four years. She had both ovaries removed without relief. She was free of abdominal pain and LBP immediately following a manual correction in posterior innominate rotation.
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I received an email from a PT in Hong Kong who teaches incontinence training there and who had been to my workshop. She stated that following posterior innominate rotation for LBP the patients no longer required treatment for incontinence. Fukushima found that subluxation of the suboccipital joint provokes severe neck pain and that intra-capsular or pericapsular injection into the SIJ can give immediate relief of the neck pain. (28) He recommended that therapy should be initiated to the SIJ dysfunction to relieve neck pain.
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Shaw reported on 1000 consecutive cases of low back pain using changes in apparent leg length and movement of the pelvis from asymmetry to symmetry to correctly identify and treat the dysfunction of the sacroiliac joints. (29) He found that 98% of all patients had at least some degree of SIJD and his surgical incidence for herniated discs dropped to 0.2%. Shaw has been ignored. More recently Borowsky and Fagen have suggested that SIJD is far more common than is generally thought. (30)
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References
Murakami et al compared periarticular and intraarticular injections for diagnosis of dysfunction of the sacroiliac joint. (31) Using periarticular injections in 25 consecutive patients with SIJ pain they found that it was effective in all patients. Yeoman reported that sacroiliac arthritis was responsible for 36% of the cases of sciatica. (32) Davis and Lentle used technetium-99m stannous pyrophosphate bone scanning with quantitative sacroiliac scintigraphy in 50 female patients with idiopathic low back pain syndrome and found that 22 patients (44%) had sacroiliitis. Eight of these patients (36%) had unilateral sacroiliitis and 14 (64%) had bilateral sacroiliitis. Of the 22 patients with abnormal scans, 20 had normal radiographs. (33) Timgren and Soinila found a reversible pelvic asymmetry, assessed the prevalence of reversible pelvic obliquity and its subgroups among a given population and the results of medical intervention. (34) Conclusions During normal ambulation the sacral X axes serve as a reservoir of kinetic energy and function to decrease the forces of loading during normal gait through balanced biotensegrity mechanics. Posterior innominate rotation causes the ilial tuberosity on the loading side to cause the sacrum to flex laterally and rotate. Oblique force couples distribute the loading through active ligaments to decrease loading to the femoral head. The sacrum functions as a biotensegrity unit during normal gait. Any dysfunction in anterior innominate rotation will alter these mechanics. Dysfunction only occurs when the line of gravity moves anterior to the acetabular axis with lifting, bending, lowering, pregnancy, obesity, lumbar lordosis or forward head posture and all can cause anterior rotation of the innominates on the sacrum. Anterior innominate rotation occurs on an acetabular axis, increases the lumbosacral angle, increases apparent leg length (usually bilaterally), increases shear at L5-S1, increases the lordotic posture, and tends to decrease tension on the sacrotuberous ligaments and iliolumbar ligaments. The ilial tuberosities lay immediately cephalad to the sacrum and normally only respond functionally to gravity and posterior innominate rotation. (Figure 1) The complexity of this multiaxial joint is only vulnerable to a dysfunction in anterior innominate rotation. Corrective exercises in manual posterior innominate rotation are very basic, simplistic and immediately effective. Correction of this dysfunction causes a measurable movement caudad and medially of the PSIS on the sacrum (35). Patients do not usually require professional assistance. There is no danger in overcorrection because of the bony blockage of the ilial tuberosities by the sacrum. I invite you to visit my website for further instruction. www.thelowback.com How it works, why it hurts and how to fix it. My bibliography is on my website. A course on the pelvis for professionals is available at http://www.greatseminarsonline.com . In all likelihood there is probably no other structures in the pelvis that have been more frequently misunderstood, overlooked and neglected in the past hundred years than the critical sacral X axes to the detriment of essentially all research on low back pain and the pelvis.
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18. Bernard TN, Cassidy JD. Sacroiliac joint Syndrome: pathophysiology, diagnosis and management. In: Frymoyer JW(ed) The Adult Spine, vol. 2. Raven Press, New York. 1991; 2107-2131
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19. Fortin JD et al. Sacroiliac joint pain referral patterns upon application of a new injection. Arthrography technique I: Asymptomatic volunteers. Spine. 1994a; 19(13):1475-1482
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21. Grieve GP. The sacro-iliac joint. Physiotherapy. 1976; 62:384
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22. Calguneri M, Bird HA, Wright V. Changes in joint laxity occurring during pregnancy. Ann Rheum Dis. 1982; 41:126-128
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23. Grieve GP. Common Vertebral Joint Problems. New York, NY. Churchill Livingstone Inc. 1981; 283
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24. Sunderland S, Bradley KC. Stress-strain phenomena in human spinal nerve roots. Brain. 1971; 94:120 25. Baer WS. Sacro-iliac strain. Bull. Johns Hopkins Hosp. 1917; 28: 159
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26. Mennell JB. The science and art of Joint manipulation: The spinal column. J & A Churchill Ltd, London. vol 2. 1952; 90
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27. Norman GF. Sacroiliac disease and its relationship to lower abdominal pain. American Journal of Surgery. 1968; 116:54-46
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28. Fukushima M. Radiographic findings before and after manual therapy for acute neck pain. International Musculoskeletal Medicine. 2008; 30(1): 1-19
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29. Shaw JL. The role of the sacroiliac joint as a cause of low back pain and dysfunction. In Vleeming A et al (eds): The First Interdisciplinary World Congress on Low Back Pain and its Relation to the Sacroiliac Joint. San Diego, CA 5-6 November 1992; 67-80 30. Borowsky CD, Fagen G. Sources of sacroiliac region pain: Insights gained from a study comparing standard intra-articular injection with a technique combining intra- and peri-articular injection. Arch Phys Med. 2008; 89:2048-2056
26 27 28
31. Murakami E. Tanaka Y, Aizawa T. Ishizuka M, Kokubun S. Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: Prospective comparative study. J of Orthopaedic Science. 2007; 12(3): 274-280
29 30 31
32. Yeoman W. The relation of arthritis of the sacroiliac joint to sciatica. Lancet .1928; 2:1119-1122 33. Davis P, Lentle BC. Evidence for sacroiliac disease as a common cause of low backache in women. Lancet . 1978; 2:496-497
32 33 34
34. Tingren J, Soinila S. Reversible pelvic asymmetry. J Manipulative Physiol Ther. 2006; 29(7):561-5
35
Addendum
36
http://www.greatseminarsonline.com Course for credit
37
http://www.thelowback.com. How it works, why it hurts and how to fix it.
35. DonTigny RL. Measuring PSIS movement. Clinical Management. 1990; 10:43-44
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DonTigny RL: The Science of Pelvic Dynamics and the Subluxation of the Sacral X Axis. (650 PP slides, 150 illustrations, 18” video, more.) Belgrade , Montana, (c) registered 2001 and continuously revised through 2016 (Download. $499.00 through www.thelowback.com).
4 5
Physical therapy, kinesis and biomechanics instructors same course, but with permanent free distribution of copies to students for $4,995.00.
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http://www.getprolo.com http://www.whiplash101.com/tag/sciatica/www.whiplash101.com/tag/sciatica/ http://www.americaspodiatrist.com/2010/06/is-your-pelvis-causing-your-back-knee-hip-neck-or-foot-pain/ http://www.hicksvillephysicaltherapy.com/Conditions-Treated/Lower-Back-Pain/a~3298--c~343143/article.html http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=50535 http://kopast-physicaltherapy.blogspot.com/2011_03_01_archive.html http://www.Endyourbackpainnow.com, or http://www.SamVisnic.com.
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FYI List of a few references on the pelvis and sacroiliac joint
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McConnell CP, Teall CC: the Practice of Osteopathy. Third Edition. Kirksvillle, Mo., The Journal Printing Co. 1906
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Cunningham DJ, cited by Dwight T, et al: Human Anatomy. Including Structure and Development and Practical Considerations. Edited by GA Piersol. Philadelphia, JB Llippincott Co.,1907, p 346
19
Platt R: Pelvic technique. J Am Osteopath Assoc 1486-88, 1914.
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Baer WS: Sacro-iliac strain. Bull. Johns Hopkins Hosp. 28: 159, 1917
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Smith-Petersen M, Rogers W: End-result study of arthrodesis of the sacroiliac joint for arthritis, traumatic and non-taumatic. Journal of Bone and Joint Surgery 8:118-136, 1926
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Sciatica was thought to be caused by dysfunction in the sacroiliac joint in the early 1900s. In 1928 Yeoman reported that sac roiliac arthritis was responsible for 36% of the cases of sciatica. Yeoman W: The relation of arthritis of the sacroiliac joint to sciatica. Lancet 1928: 2:1119-1122
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Chamberlain, WE: The Symphysis Pubis in the Roentgen Examination of the Sacroiliac Joint. Am J Roentgenol Radium Ther Nucl Med 24:621-625, 1930
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Frieberg AH, Vinke TH: Sciatica and the sacroiliac joint. J Bone & Joint Surg. 16:126, 1934
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Bailey HW, Beckwith CG: Short leg and Spinal anomalies. Their incidence and effects on spinal mechanics. JAOA 36:319-327, 1937
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Smith-Petersen MN: Arthrodesis of the Sacroiliac Joint. A New Method of Approach. J Orthop Sur 3:400-405, 1938
32 33 34 35 36
Rauber-Kopsch found that a part of the sciatic nerve passed through the piriformis muscle and joined the other portion of the nerve to form a main trunk at the caudal margin of the muscle. Rauber-Kopsch F: Lehrbuch and Atlas der Anatomie des Menschen. Edited by Kopsch F, Thierme G, Leipzig 1940-43
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Platt H: Backache - Sciatica syndrome and intervertebral disk. Rheumatism 4:218, 1948
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Shuman D: Technic for treating instability of the joints by sclerotherapy. Osteopathic Profession, May 1953
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Weisl H: The relation of Movement To Structure in the Sacroiliac Joint. PhD Thesis, Manchester, England, University of Manchester, 1953
Anderson Rl, Peterson Vl. Clinical use of the Chamberlain technic in sacroiliac conditions. J Am Med Assoc 1944;124:269–71.
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1
Weisl H. Movement of the sacroiliac joint . Acta Anat (Basal)23;80-91, 1955
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Kallio KE: The problem of back pain and sciatica: a report of recent experiences. Duodecim 1-2:1, 1955
3
Norman GF, May A: Sacroiliac Conditions Simulating Intervertebral disc Syndrome. West J Surg Obstet Gynecol 461-462, 1956
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Hackett GS, Huang TC: Prolotherapy for sciatica from weak pelvic ligaments and bone dystrophies. Clinical Medicine 8(12):23022316, 1961
6
Norman GF: Sacroiliac disease and its relationship to lower abdominal pain. Am J Surg 116:54-56, 1968
7
Grant JCB: A Method of Anatomy. Descriptive and Deductive. Sixth Edition. Baltimore, Williams & Wilkins Co., 1968
8 9
Coventry MB, Tapper EM. Pelvic instability: a consequence of removing iliac bone for grafting. J Bone Joint Surg Am. 1972 Jan;54(1):83–101
10
DonTigny, RL: Evaluation, manipulation and management of anterior dysfunction of the sacroiliac joint. The D.O. 14:215-226, 1973
11
Hiltz DL: The sacroiliac joint as a source of sciatica: A case report. Phys Ther 56:1373, 1976.
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DonTigny, RL: Letter to Editor: Sciatica and the Sacroiliac Joint. PT March 1977, p 143
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LaBan MM, Meerschaert JR, Taylor RS, Tabor HD. Symphyseal and sacroiliac joint pain associated with pubic symphysis instability. Arch Phys Med Rehabil 1978;59:470–2.
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DonTigny, RL: Dysfunction of the sacroiliac joint and its treatment. JOSPT 1:13-25, 1979
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Grieve GP: Common Vertebral Joint Problems, New York, NY, Churchill Livingstone Inc, 1981
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Farfan HF, Kirkaldy-Willis WH. The present status of spinal fusion in the treatment of lumbar intervertebral joint disorders. Clin Orthop Relat Res. 1981 Jul-Aug;(158):198–214
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DonTigny, RL: Function and pathomechanics of the sacroiliac joint. Phys Ther 65:35-44, 1985
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Ongley ML, Klein RG, Dorman TA et al: A new approach to chronic back pain. Lancet 2:143-6, 1987
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Sturesson B, Selvik G, Uden A: Movements of the sacroiliac joints. A roentgen stereophotogrametric analysis. Spine 14:162-165, 1989
31 32
DonTigny, RL: Sacroiliac Dysfunction, Recognition and Treatment. Postgraduate Advances in Physical Therapy. Course III, Berryville, VA, Forum Medicum, Inc. 1990, pp 1-33
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DonTigny RL: Anterior dysfunction of the sacroiliac joint as a major factor in the etiology of idiopathic low back pain syndrome. Physical Therapy 70:250-265, 1990
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DonTigny, RL: Measuring PSIS movement. Clinical Management 10:43-44, 1990
36 37
Vleeming A. The Sacroiliac Joint: A Clinical Anatomical Biomechanical and Radiological Study. 1990. Thesis Erasmus University Rotterdam. Rotterdam.
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Vukicevic S, Madrusic A, Stavljenic A, Vujicic C, SkavicJ, Mukicevic D, Holigraphic analysis of the human pelvis. Spine 16:2 09-214, 1991
Davis P, Lentle PC: Evidence for sacroiliac disease as a common cause of low backache in women. Lancet 2:496-97, 1978
Gajdosik R, Simpson R, Smith R, DonTigny RL: Pelvic Tilt: Intratester reliability of measuring the standing position and rang e of motion. Phys Ther 65:168-174, 1985
DonTigny, RL: Function, Dysfunction and Manual Treatment of the Sacroiliac Joint. In Nwuga VC (ed): Manual Treatment of Back Pain. Malabar, Florida, Robert E. Krieger Publishing Co., 1985, Chpt 8, pp 122-152
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Alderink, , GJ: The Sacroiliac Joint: Review of Anatomy, Mechanics, and Function Journal of Orthopaedic & Sports Physical Therapy, 1991, Volume: 13 Issue: 2 Pages: 71-84 doi:10.2519/jospt.1991.13.2.71
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DonTigny, RL: Sacroiliac joint as a major source of low back pain. Back Pain Monitor, April 1991, pp 55-58
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DonTigny, RL: Sacroiliac joint dysfunction responds well to manual therapy. Back Pain Monitor, May 1991
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Shaw, JT: The role of the sacroiliac joint as a cause of low back pain and dysfunction. In: Vleeming A, Mooney V , Snijders CH, Dorman T(eds): First Interdisciplinary World Congress on Low Back Pain and its Relation to the Sacroiliac Joint. San Diego, CA November 5-6, 1992, pp 67-80 Shaw, orthopedic surgeon at the Topeka Back and Neck Center, did a study of 1,000 consecutive patients with low back pain and found that 98% had this dysfunction. His surgical rate for herniated discs dropped to 0.2%.
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Paris VP. Differential diagnosis of sacroiliac joints from lumbar spine dysfunction. In: Vleeming A, Mooney V, Snidjers CJ, Dorman T, editors. Proceedings of the First Interdisciplinary World Congress on Low Back Pain and its Relation to the Sacroiliac Joi nt. Rotterdam: European Conference Organizer; 1992. p 1-64.
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DonTigny, RL: Mechanics and treatment of the sacroiliac joint. Journal of Manual & Manipulative Therapy, 1:3-12, 1993
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DonTigny, RL: Function of the lumbosacroiliac complex as a self-compensating force couple with a variable, force-dependent transverse axis: A theoretical analysis. JMMT, 2:87-93, 1994
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DonTigny, RL: The DonTigny low back pain management program. JMMT, 2:163-168, 1994
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Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995;20:31-7.
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Smidt GS, McQuade K, Wei SH, Barakatt E: Sacroiliac kinematics for reciprocal stride positions. Spine 20(9):1047-1054, 1995
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Moore M: Diagnosis and surgical treatment of chronic painful sacroiliac dysfunction. Vleeming A, Mooney V Dorman T, Snijders R (eds): Second Interdisciplinary World Congress on Low Back Pain. san Diego, CA, Nov 9-11, pp339-354 1995
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Dorman TA, Brierly S, Fray J, Pappani K: Muscles and pelvic clutch: hip adductor inhibition in anterior rotation of the ilium. Journal of Manual and Manipulative Therapy 1995, 3:85-90
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Dannanberg H J: Lower back pain as a gait-related repetitive motion injury. In Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R (eds): Movement, Stability & Low Back Pain: The Essential Role of the Pelvis, London, Churchill Livingstone, 1997 pp 253-267]
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Keating JG, Avillar MD, Price M: Sacroiliac joint arthrodesis in selected patients with low back pain. In: Vleeming A, Mooney V Dorman T, Snijders R (eds): Movement, Stability & Low Back Pain: The Essential Role of the Pelvis. London, Churchill Livingst one,
Snijders CJ, Vleeming A, Stoeckart R. Transfer of lumbosacral load to iliac bones and legs Part 1: Biomechanics of self-bracing of the sacroiliac joints and its significance for treatment and exercise. Clin Biomech (Bristol, Avon) 1993;8:285–94
DonTigny, RL: Functional Biomechanics and Management of the Pathomechanics of the Sacroiliac Joint. In Dorman TA (ed): SPINE: State of the Art Reviews. Philadelphia, PA, Hanley & Belfus, Inc. 1995, Chpt 14
Vleeming A, Pool-Goudzwaard AL, Hammudoghlu D, Stoeckart R, Snijders CJ, Mens JMA. The function of the long dorsal sacroiliac ligament: its implication for understanding low back pain. Spine (Phila Pa 1976) 1996;21:556–62. Maigne JY, Aivaliklis a, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests i n 54 patients with low back pain. Spine 1996;21:1889–92
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pp 573-586, 1997 Fortin JD, Falco FJE. The Fortin finger test: an indicator of sacroiliac pain. Am J Orthop MEAD- 1997;26:477–80.
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Lippitt AB: Percutaneous fixation of the sacaroiliac joint. In: Vleeming A, Mooney V Dorman T, Snijders R (eds): Movement, Stability & Low Back Pain: The Essential Role of the Pelvis. London, Churchill Livingstone, pp 587-594, 1997 Mens JMA, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ. The active straight leg raising test and mobility of the pelvic joints. Eur Spine J 1999;8:468–73.
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DonTigny, RL: Critical analysis of the sequence and extent of the result of the pathological release of self- bracing of the sacroiliac joint. Concurrently in JMMT 7:173-181, 1999 and J of Ortho Med (UK) 22:16-23,2000
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Slipman CW, Lipetz JS, Plastaras CT, et al. Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome. Am J Phys Rehabil 2001;80:425-32.
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Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Man Ther 2005;10:207–18
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Maigne JY, Planchon CA. Sacroiliac joint pain after lumbar fusion: a study with anesthetic blocks. Eur Spine J 2005;14:654-8.
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Fortin JD, Washington WJ, Falco FJE. Three pathways between the sacroiliac joint and neural structures. Am J Neuroradiol 1999;20:1429–34.
Damen L, Buyruk HM, Güler-Uysal F, Lotgering FK, Snijders CJ, Stam HJ. with asymmetric laxity of the sacroiliac jointsPelvic pain during pregnancy is associated. Acta Obstet Gynecol Scand 2001;80:1019–24. Damen L, Spoor CW, Snijders CJ, Stam HJ. Does a pelvic belt influence sacroiliac joint laxity? Clin Biomech 2002;17:495–8. Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 2003; 28:1593-600. Dreyfuss P, Dreyer SJ, Cole A, Mayo K. Sacroiliac joint pain. J Am Acad Orthop Surg 2004;12:255-65. Al-Eisa E, Egan D, Wassersug R. Fluctuating asymmetry and low back pain. Evol Hum Behav 2004;25:31–7.
DonTigny, RL: Critical analysis of the functional dynamics of the sacroiliac joints as they pertain to normal gait. J of Orthopaedic Medicine (UK) 27:3-10, 2005
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DonTigny, RL: Pathology of the sacroiliac joint, its effect on normal gait and its correction. J of Orthopaedic Medicine (UK) 27:6169, 2005
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Laslett M, Aprill CN, McDonald B. Provocation sacroiliac joint tests have validity in the diagnosis of sacroiliac joint pain. Arch Phys Med Rehabil 2006;87:874-5. Tingren J, Soinila S. Reversible pelvic asymmetry. J Manipulative Physiol Ther. 2006; 29(7):561-5.
Forst SL, Wheeler MT, Fortin JD, Vilensky JA. The sacroiliac joint: anatomy, physiology and clinical significance. Pain Physician 2006;1:61-7. DonTigny, RL: A detailed and critical biomechanical analysis of the sacroiliac joints and relevant kinesiology: the implications for lumbopelvic function and dysfunction. In Vleeming A, Mooney V, Stoeckart R (eds): Movement, Stability & Lumbopelvic Pain: Integration of research and therapy. Churchill Livingstone (Elsevier). Edinburgh, 2007, pp 265-279
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Gracovetsky S: Stability or controlled instability. In Vleeming A, Mooney V, Stoeckart R (eds) Movement, Stability & Lumbopelvic Pain: Integration of research and therapy. Churchill Livingstone (Elsevier), Edinburgh, 2007, pp 279-293
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Murakami E. Tanaka Y, Aizawa T. Ishizuka M, Kokubun S. Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: Prospective comparative study. J of Orthopaedic Science. 2007; May 12(3):274-280.
5 6
Fukushima M: Radiographic findings before and after manual therapy for acute neck pain. International Musculoskeletal Medicine, 30(1): 1-19, 2008
7 8 9 10 11 12 13 14 15 16 17 18
Borowsky, CD, Fagen, G: Sources of Sacroiliac Region Pain: Insights Gained From a Study Comparing Standard Intra-Articular Injection With a Technique Combining Intra- and Peri-Articular Injection. Arch Phys Med Rehabil Vol 89, November 2008 Preece SJ, Willan P, Nester CJ, Graham-Smith P, Herrington L, Bowker P: Variation in pelvic morphology may prevent the identification of anterior pelvic tilt. J Man Manip Ther 2008;16:113–7. Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther 2008;16:142–52.
Gnat R, Saulicz E, Biały M, Kłaptocz P. Does Pelvic Asymmetry always Mean Pathology? Analysis of Mechanical Factors Leading to the Asymmetry. J Hum Kinet 2009;21:23–32.
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DonTigny, RL: Sacroiliac 101; Form and Function; A biomechanical study. Journal of Prolotherapy 3:561-567, 2011 full text from https://www.researchgate.net
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DonTigny RL: Sacroiliac 201: Dysfunction and Management A biomechanical solution, J of Prolotherapy, 3(2): 644-652, 2011
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Yoshihara H: Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge. Eur Spiine J Sep 21(9)1788-96, 2012. 35.
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DonTigny, RL: Superstition Versus Science. The treatment of dysfunction of sacroiliac joint biomechanics. Advance for Physical Therapy & Rehab Medicine. 22:28-30, 2011
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Nagamoto, Y: Sacroiliac joint motion in patients with degenerative lumbar spine disorders. Journal of neurosurgery. Spine 23(2):18 · May 2015 Salman OH, Gad GS: Randomized, controlled blind study comparing sacroiliac intra-articular steroid injection to radiofrequency denervation for sacroiliac joint pain. Dec 2015 · Egyptian Journal of Anaesthesia
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DonTigny RL: Evidence of Errors That Have Stymied Low Back Pain Research: A plea for more appropriate care. Unpublished 2016
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DonTigny RL: The Science of Pelvic Dynamics and the Subluxation of the Sacral Axis. Download. Bozeman, Montana, (c) registered 2001 and continuously revised through 2016 ($495.00 through www.thelowback.com)
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http://www.greatseminarsonline.com Corrections on actual patents with immediate relief of pain. Five CEUs
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www.kalindra.com/sacroiliac2.htm www.thelowback.com
Available in
DonTigny RL: The Four Types of Pelvic Movement: Dysfunction as a Pseudo-Multifactorial Lesion Unpublished. 2016
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