Sacrum Diagnosis Chart: Mastering Sacral Dysfunction and Muscle Energy Techniques

Introduction

Low back pain stands as a pervasive health issue, challenging both diagnosis and effective treatment strategies within the medical community. It’s estimated that in a significant majority of cases, approximately 85%, the precise origin of low back pain remains elusive. While medical education often points towards musculoskeletal problems as a primary source, pinpointing specific causes is uncommon, leading to persistent discomfort and limitations that significantly diminish patients’ quality of life. Muscle Energy Techniques (METs) have emerged as a crucial modality in addressing structural imbalances contributing to low back pain, particularly when sacral dysfunction is implicated. The sacrum, a keystone structure at the base of the spine, plays a vital role in weight transfer and proper gait mechanics. When dysfunctional, it can be a significant source of pain and mobility issues.

Osteopathic Manipulative Treatment (OMT), with its emphasis on manual techniques like METs, provides healthcare providers with powerful tools for diagnosing and treating the structural underpinnings of back pain. Developed initially by Dr. Fred Mitchell, Sr. in the 1950s, METs leverage the body’s intrinsic healing capabilities. These techniques are largely categorized as direct and active treatments, where patients actively participate by generating a force against a counterforce applied by the practitioner. Among the nine recognized physiological principles of MET, post-isometric relaxation is particularly prominent and frequently employed. This method involves positioning the patient against a restrictive barrier, prompting an isometric contraction that leads to muscle relaxation and joint mobilization. This process effectively targets soft tissue restrictions, reduces pain, and enhances local circulation.

Sacral motion within the sacroiliac joint is complex, giving rise to ten potential somatic dysfunctions. These dysfunctions, including torsions, unilateral flexions and extensions, and bilateral conditions, can significantly impact biomechanics and overall patient well-being. This article provides a comprehensive guide to understanding and diagnosing sacral dysfunctions, offering a detailed Sacrum Diagnosis Chart framework and exploring the METs utilized for their effective correction. By mastering these diagnostic and treatment approaches, healthcare professionals can significantly improve patient outcomes and quality of life.

Anatomy and Physiology of the Sacrum

A foundational understanding of muscle physiology is essential for effectively applying METs. Muscle contraction exists in four primary forms: isolytic, concentric, isometric, and eccentric. Isolytic contraction involves muscle lengthening against an external force, while concentric contraction refers to muscle shortening during activation. Isometric contraction occurs when muscle tension increases without a change in muscle length, and eccentric contraction is characterized by muscle lengthening while under tension.

Muscles are composed of numerous spindles, each containing extrafusal and intrafusal muscle fibers. Extrafusal fibers, responsible for muscle force generation, are innervated by alpha (α) motor neurons. Intrafusal fibers, located within the spindle, are innervated by gamma (γ) motor neurons and are crucial for sensing muscle length and change in length. Sensory innervation includes Ia and II fibers from muscle spindles and Ib fibers from Golgi tendon organs situated at the myotendinous junction. Golgi tendon organs are mechanoreceptors that respond to increased muscle tension, initiating a negative feedback loop to prevent excessive muscle contraction via Ia fibers. This mechanism is central to the post-isometric relaxation principle in MET, where activating the Golgi tendon organ is key to achieving muscle relaxation.

Post-isometric relaxation, the most commonly used type of MET, operates on the principle that following an isometric contraction, a muscle enters a refractory state, allowing for passive stretching without triggering a reflexive contraction. By positioning the patient against a barrier, tension is maximized within the targeted muscle fibers. The patient’s isometric contraction against the physician’s counterforce activates the Golgi tendon organ. Upon activation, the muscle relaxes through Ia fiber inhibition, enabling the physician to further passively stretch the muscle during this relaxed, refractory phase.

The sacrum itself is a triangular bone located at the inferior end of the vertebral column, formed by the fusion of five vertebrae during the first year of life. It articulates superiorly with the fifth lumbar vertebra, inferiorly with the coccyx, and laterally with the ilia at the sacroiliac joints. This anatomical arrangement is critical for palpation and identifying sacral landmarks. A primary function of the sacrum is load transfer, contributing to smooth and efficient gait.

Image: Anatomical illustration of the sacrum posterior view, emphasizing key landmarks relevant for sacrum diagnosis.

The sacroiliac joint, where the sacrum articulates with the ilium, has been recognized as a source of low back pain since the early 20th century. This L-shaped diarthrodial joint contains synovial fluid and is surrounded by a fibrous capsule. Stability is provided by strong ligamentous and tendinous attachments, including contributions from the gluteus maximus and piriformis muscles, and the thoracolumbar fascia extending from the latissimus dorsi.

The sacrum’s inverted triangular shape features a broad base superiorly and an apex inferiorly. The sacral base is palpated just inferomedial to the posterior superior iliac spines (PSIS). The inferior lateral angles (ILAs) are located at the most inferior aspect of the sacrum, identifiable by palpating inferiorly along the dorsal surface until a drop-off superior to the coccyx is felt. These landmarks are crucial for assessing sacral motion and diagnosing dysfunctions, as outlined in the sacrum diagnosis chart approach.

Contrary to earlier beliefs of sacroiliac joint immobility, modern studies have demonstrated complex motions at this joint. The sacrum rotates around three transverse axes: superior, middle, and inferior. The superior transverse axis, at the S1 level, is influenced by respiration and craniosacral motion. The middle transverse axis, at S2, is posture-dependent and acts as the primary rotational axis against the innominate bones. The inferior transverse axis, at S3, governs innominate movement relative to the sacrum. During gait, the middle transverse axis shifts to become either the right or left oblique axis to accommodate weight transfer and innominate motion, predisposing to sacral somatic dysfunctions. The right oblique axis runs from the right sacral base to the left ILA, and the left oblique axis runs from the left sacral base to the right ILA. These multiple axes contribute to the sacrum’s gyroscopic effect, resulting in seemingly limited motion.

Nutation describes the anteroinferior movement of the sacral base, while counternutation is its posterosuperior movement. Nutation typically occurs during exhalation and lumbar spine extension, whereas counternutation occurs during inhalation or lumbar flexion. Clinicians can palpate these motions by monitoring the sacral base for anterior or posterior translation during trunk extension and flexion, respectively, providing dynamic information for sacrum diagnosis.

The sacrum’s movement is intricately linked to the lumbar spine due to extensive fascial, muscular, and ligamentous connections. Rotation of the fifth lumbar vertebra (L5) induces sacral rotation in the opposite direction over an oblique axis. Side-bending of L5 engages the oblique axis on the same side. This reciprocal relationship is essential for maintaining level gaze during ambulation, a crucial compensatory mechanism. A thorough understanding of these anatomical and biomechanical relationships is fundamental for accurate sacrum diagnosis and effective osteopathic treatment.

Indications for MET in Sacral Dysfunction

MET is primarily indicated for treating low back pain associated with diagnosed sacral dysfunction. However, the sacrum’s neurological connections via the sacral plexus extend beyond musculoskeletal pain. Sacral dysfunction can influence parasympathetic tone, potentially affecting the large intestine and genitourinary systems. Consequently, conditions such as constipation and dysmenorrhea may also benefit from MET directed at sacral somatic dysfunction. Therefore, MET can be considered a therapeutic option for a broader range of conditions beyond just musculoskeletal complaints, when a sacral component is identified through a comprehensive sacrum diagnosis chart assessment.

Contraindications for MET

METs are generally considered safe with a low risk of complications. The controlled, gentle forces used to lengthen contracted muscles make MET tolerable even for patients in acute pain. However, certain contraindications must be considered. MET should be avoided or used with extreme caution in cases of:

• Muscle ruptures or tears in the treatment area
• Fractures in the targeted region
• Ligament rupture in the spinal or vertebral joints
• Lack of patient cooperation or inability to follow instructions

These contraindications ensure patient safety and prevent potential adverse events during MET application. A thorough patient history and physical examination are crucial to rule out these contraindications prior to employing MET for sacral dysfunction.

Equipment for Sacrum Diagnosis and MET Treatment

Minimal equipment is required for sacrum diagnosis and MET treatment. A flat, padded surface such as a hospital bed or massage table is sufficient. Adjustable table height can enhance clinician comfort and facilitate patient positioning. No specialized or costly equipment is necessary, making MET a readily accessible treatment modality in various clinical settings.

Preparation: Sacrum Diagnosis Chart and Assessment

Diagnosing sacral somatic dysfunction is a multi-step process, distinct from diagnosing other vertebral segments due to the ten potential sacral dysfunctions. A systematic approach, utilizing both static and dynamic tests, is essential for accurate sacrum diagnosis. The sacrum diagnosis chart framework helps organize these findings for a clear and actionable diagnosis.

Dynamic Tests

1. Seated Flexion Test: This is a cornerstone dynamic test in sacrum diagnosis. With the patient seated, the innominates are stabilized, isolating sacral motion. The clinician palpates inferior to the PSISs with their thumbs as the patient flexes forward. A positive test is indicated when one PSIS moves more superiorly (cranially) than the other. The side with the more cranial PSIS is considered the side of sacral dysfunction. In sacral torsions, the oblique axis is located at the sacral base opposite the “stuck” side. For unilateral dysfunctions, the positive seated flexion test side corresponds to the side of dysfunction. A negative test may indicate no sacral dysfunction or bilateral dysfunction.

2. Spring Test: The patient is prone. The clinician applies a slow, downward force through the lumbosacral junction. A negative spring test exhibits a soft, bouncy return, indicating normal motion. A positive test presents a hard endpoint, suggesting restricted anterior sacral base motion, often seen in bilateral sacral extension or posterior sacral torsions.

3. Sphinx Test: This test helps differentiate between anterior and posterior sacral torsions. Initially, in prone position, the clinician observes sacral sulci and ILAs for asymmetry. The patient then rises to a sphinx position (supported on elbows), inducing lumbar extension and sacral flexion.

• Forward Sacral Torsion/Flexed Sacral Dysfunction: If asymmetry corrects or pain decreases in sphinx position.
• Backward Sacral Torsion/Extension Dysfunction: If asymmetry worsens or pain increases in sphinx position.

Static Tests

Static palpation is crucial for identifying positional asymmetries indicative of sacral dysfunction. Clinicians palpate:

• Sacral Sulcus (Sacral Base): Located finger-width medial and inferior to the PSIS.
• Inferior Lateral Angle (ILA): The most inferior aspect of the sacrum.

Sacrum Diagnosis Chart Framework:

Dysfunction Type	Seated Flexion Test	Sacral Sulcus (Side of Dysfunction)	ILA (Side of Dysfunction)	Spring Test	Sphinx Test
Unilateral Sacral Flexion	Positive	Deep	Posterior	–	–
Unilateral Sacral Extension	Positive	Shallow	Anterior	–	–
Anterior Sacral Torsion	Positive	Deep (Opposite Seated Flexion)	Posterior (Same as Seated Flexion)	Negative/Positive	Corrects/Improves
Posterior Sacral Torsion	Positive	Deep (Opposite Seated Flexion)	Posterior (Same as Seated Flexion)	Positive	Worsens/Painful
Bilateral Sacral Flexion	Negative	Equal Sulci	Equal ILAs	Negative	Corrects/Improves
Bilateral Sacral Extension	Negative	Equal Sulci	Equal ILAs	Positive	Worsens/Painful

This sacrum diagnosis chart provides a structured approach to synthesize findings from dynamic and static tests, leading to a precise diagnosis of sacral dysfunction.

Technique or Treatment: METs for Sacral Dysfunctions

Various manual therapies address sacral and sacroiliac joint issues. This section focuses on METs with post-isometric relaxation, a cornerstone of osteopathic practice. Treating the sacrum with MET can be complex due to positioning challenges. Maintaining lumbar spine mobility, particularly at L5, is crucial as L5 motion reciprocally influences sacral mechanics. Remember, the oblique axis for sacral rotation aligns with the same side of L5 side-bending, while sacral rotation opposes L5 rotation.

MET for Anterior Sacral Torsion (e.g., Left-on-Left)

1. Patient Position: Sims position, chest and torso prone, lower body flexed on the side of the axis (left side for left-on-left dysfunction). Upper body rotated to restrict motion above L5. Hips and legs flexed until motion is localized at S2.
2. Physician Action: Physician pushes bilateral legs towards the table to engage the barrier.
3. Patient Action (Isometric Contraction): Patient instructed to lift both feet towards the ceiling against physician’s resistance for 5 seconds.
4. Relaxation and Barrier Engagement: Patient relaxes. Hip flexion increased, feet lowered towards the ground to engage the next barrier.
5. Repetition: Repeat cycles 3-5 times. Reassess sacral dysfunction post-treatment.

MET for Posterior Sacral Torsion (e.g., Right-on-Left)

1. Patient Position: Lateral recumbent, side of oblique axis (left side for right-on-left) facing the table, knees flexed. Upper body rotated posteriorly to immobilize segments above L5. Superior knee flexed until motion at S2. Inferior leg extended, superior leg dropped off the table. Upper leg lowered until motion detected at monitoring hand.
2. Physician Action: Stabilizes upper leg to create resistance.
3. Patient Action (Isometric Contraction): Patient lifts upper leg towards the ceiling against physician’s resistance for 5 seconds.
4. Relaxation and Barrier Engagement: Patient relaxes. Hip extension increased, leg lowered towards the floor to engage the next barrier.
5. Repetition: Repeat cycles 3-5 times. Reassess sacral dysfunction post-treatment.

MET for Unilateral Sacral Flexion (e.g., Left Unilateral Flexion)

1. Patient Position: Prone, leg on the side of positive seated flexion (left leg) slightly abducted and internally rotated (to isolate sacroiliac joint motion).
2. Physician Action: Heel of hand on ipsilateral ILA (left ILA). Senses sacral motion during respiration.
3. Respiratory Assist: As patient inhales (counternutation), follow ILA anteriorly and cephalad. Maintain resistance during exhalation to prevent posterior ILA motion.
4. Repetition: Repeat cycles 3-5 times. Reassess sacral mobility.

MET for Unilateral Sacral Extension (e.g., Right Unilateral Extension)

1. Patient Position: Prone, leg on the side of positive seated flexion (right leg) slightly abducted and internally rotated.
2. Physician Action: At patient’s head, base of hand on dysfunctional sacral base (right sacral base). Patient moves to sphinx position (lumbar extension).
3. Respiratory Assist: Patient inhales. As patient exhales, follow sacral base anterior and caudad. Maintain resistance during inhalation to prevent posterior sacral base motion.
4. Repetition: Repeat cycles 3-5 times. Reassess sacral symmetry.

MET for Bilateral Sacral Flexion and Extension

Positioning mirrors unilateral techniques, both legs abducted and internally rotated.

• Bilateral Flexion: Physician force on sacral apex during patient inhalation.
• Bilateral Extension: Physician force on sacral base during patient inhalation.

Image: Illustration depicting a muscle energy technique being applied to the sacrum area, showing patient and practitioner positioning.

Complications of MET

Patients should be informed about potential post-treatment muscle soreness and fatigue. Increased water intake is recommended post-treatment. Excessive force during MET can lead to inappropriate muscle recruitment and ineffective treatment. Patients should be instructed to resist only enough to engage the targeted segment, minimizing excessive force and ensuring precise muscle activation.

Clinical Significance of Sacrum Diagnosis and MET

Sacral somatic dysfunction is a common source of back pain, prompting many patients to seek medical care. Osteopathic techniques, particularly MET, offer a conservative, non-pharmacological approach to pain relief and musculoskeletal correction, improving joint range of motion.

Proper sacral mechanics are crucial for normal gait. Addressing sacral dysfunctions can enhance gait mechanics and reduce injury risk from instability. Sacroiliac joint pain, affecting up to 25% of low back pain patients, can be effectively managed by treating sacral issues without surgery or medication, significantly benefiting patient wellness and mobility.

Beyond musculoskeletal effects, sacral dysfunction may have neurological implications via the sacral plexus and parasympathetic splanchnic nerves. Addressing sacral issues may positively influence lower gastrointestinal, uterine, and bladder function, although further research is needed in this area.

MET can also be used adjunctively before high-velocity, low-amplitude techniques to enhance soft tissue relaxation, or before myofascial release techniques to address hypertonic tissues.

Crucially, sacral dysfunctions often arise from dysfunctions elsewhere in the body. Assessment and treatment should include related areas like L5, innominates, and leg-length discrepancies to ensure comprehensive and lasting correction.

Enhancing Healthcare Team Outcomes

METs offer an efficient and safe treatment option for various patient complaints, from low back pain to constipation. Interprofessional communication is vital in managing persistent low back pain, especially when considering alternatives to pharmacologic interventions like spinal injections and narcotics. MET presents a valuable non-pharmacological alternative for the healthcare team. Understanding osteopathic principles in diagnosing structural dysfunctions and the effectiveness of manual manipulation allows clinicians to provide less invasive options, potentially improving patient productivity and overall well-being despite chronic pain.

In addressing the opioid epidemic, interdisciplinary care coordination, including referrals for osteopathic evaluations and MET treatment, can enhance patient-centered care. These strategies can improve outcomes for patients with conditions linked to sacral dysfunctions, offering a holistic and less invasive approach to pain management and functional restoration.

References

1.Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005 Aug 04;6:43. [PMC free article: PMC1208896] [PubMed: 16080794]

2.DonTigny RL. Function and pathomechanics of the sacroiliac joint. A review. Phys Ther. 1985 Jan;65(1):35-44. [PubMed: 3155567]

3.Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2014 Aug 30;15:286. [PMC free article: PMC4159549] [PubMed: 25175885]

4.Franke H, Fryer G, Ostelo RW, Kamper SJ. Muscle energy technique for non-specific low-back pain. Cochrane Database Syst Rev. 2015 Feb 27;2015(2):CD009852. [PMC free article: PMC10945353] [PubMed: 25723574]

5.Fryer G, Morse CM, Johnson JC. Spinal and sacroiliac assessment and treatment techniques used by osteopathic physicians in the United States. Osteopath Med Prim Care. 2009 Apr 14;3:4. [PMC free article: PMC2676310] [PubMed: 19366458]

6.Thomas E, Cavallaro AR, Mani D, Bianco A, Palma A. The efficacy of muscle energy techniques in symptomatic and asymptomatic subjects: a systematic review. Chiropr Man Therap. 2019;27:35. [PMC free article: PMC6710873] [PubMed: 31462989]

7.Goodridge JP. Muscle energy technique: definition, explanation, methods of procedure. J Am Osteopath Assoc. 1981 Dec;81(4):249-54. [PubMed: 7319853]

8.Gash MC, Kandle PF, Murray IV, Varacallo MA. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Apr 1, 2023. Physiology, Muscle Contraction. [PubMed: 30725825]

9.Kröger S, Watkins B. Muscle spindle function in healthy and diseased muscle. Skelet Muscle. 2021 Jan 07;11(1):3. [PMC free article: PMC7788844] [PubMed: 33407830]

10.Waxenbaum JA, Woo MJ, Lu M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jan 31, 2024. Physiology, Muscle Energy. [PubMed: 32644455]

11.Cheng JS, Song JK. Anatomy of the sacrum. Neurosurg Focus. 2003 Aug 15;15(2):E3. [PubMed: 15350034]

12.Panico M, Chande RD, Polly DW, Lindsey DP, Villa TMT, Yerby SA, Brayda-Bruno M, Galbusera F. Effect of Sacropelvic Hardware on Axis and Center of Rotation of the Sacroiliac Joint: A Finite Element Study. Int J Spine Surg. 2023 Feb;17(1):122-131. [PMC free article: PMC10025848] [PubMed: 36574987]

13.Forst SL, Wheeler MT, Fortin JD, Vilensky JA. The sacroiliac joint: anatomy, physiology and clinical significance. Pain Physician. 2006 Jan;9(1):61-7. [PubMed: 16700283]

14.DonTigny RL. Anterior dysfunction of the sacroiliac joint as a major factor in the etiology of idiopathic low back pain syndrome. Phys Ther. 1990 Apr;70(4):250-65; discussion 262-5. [PubMed: 2138334]

15.Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat. 2012 Dec;221(6):537-67. [PMC free article: PMC3512279] [PubMed: 22994881]

16.Yu K, Pfotenhauer K, Pierce-Talsma S. OMT for Patients With Sacral Somatic Dysfunction. J Am Osteopath Assoc. 2018 Mar 01;118(3):e15. [PubMed: 29480923]

17.Lesho EP. An overview of osteopathic medicine. Arch Fam Med. 1999 Nov-Dec;8(6):477-84. [PubMed: 10575385]

18.Andicochea CT, Fulkerson J, Taylor BM, Portouw SJ. Manual Therapy for Chronic Low Back Pain in an F-5 Pilot. Mil Med. 2015 Oct;180(10):e1132-5. [PubMed: 26444483]

19.Task Force on the Low Back Pain Clinical Practice Guidelines. American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain. J Am Osteopath Assoc. 2016 Aug 01;116(8):536-49. [PubMed: 27455103]

20.Consorti G, Basile F, Pugliese L, Petracca M. Interrater Reliability of Osteopathic Sacral Palpatory Diagnostic Tests Among Osteopathy Students. J Am Osteopath Assoc. 2018 Oct 01;118(10):637-644. [PubMed: 30128497]

21.García-Peñalver UJ, Palop-Montoro MV, Manzano-Sánchez D. Effectiveness of the Muscle Energy Technique versus Osteopathic Manipulation in the Treatment of Sacroiliac Joint Dysfunction in Athletes. Int J Environ Res Public Health. 2020 Jun 22;17(12) [PMC free article: PMC7345493] [PubMed: 32580480]

22.Nejati P, Safarcherati A, Karimi F. Effectiveness of Exercise Therapy and Manipulation on Sacroiliac Joint Dysfunction: A Randomized Controlled Trial. Pain Physician. 2019 Jan;22(1):53-61. [PubMed: 30700068]

23.Javadov A, Ketenci A, Aksoy C. The Efficiency of Manual Therapy and Sacroiliac and Lumbar Exercises in Patients with Sacroiliac Joint Dysfunction Syndrome. Pain Physician. 2021 May;24(3):223-233. [PubMed: 33988941]

24.Noto-Bell L, Vogel BN, Senn DE. Effects of Post-Isometric Relaxation on Ankle Plantarflexion and Timed Flutter Kick in Pediatric Competitive Swimmers. J Am Osteopath Assoc. 2019 Sep 01;119(9):569-577. [PubMed: 31449303]

25.Hill CN, Romero M, Rogers M, Queen RM, Brolinson PG. Effect of osteopathic manipulation on gait asymmetry. J Osteopath Med. 2021 Nov 18;122(2):85-94. [PubMed: 34787381]

26.Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg. 2005 Nov;101(5):1440-1453. [PubMed: 16244008]

27.Gusfa D, Bashir DA, Saffarian MR. Diagnosing and Managing Sacroiliac Joint Pain. Am J Phys Med Rehabil. 2021 Apr 01;100(4):e40-e42. [PubMed: 32701634]

28.Kamali F, Zamanlou M, Ghanbari A, Alipour A, Bervis S. Comparison of manipulation and stabilization exercises in patients with sacroiliac joint dysfunction patients: A randomized clinical trial. J Bodyw Mov Ther. 2019 Jan;23(1):177-182. [PubMed: 30691749]