Etiological Factors

in Sacral Somatic Dysfunctions

Jay B. Danto, DO

Abstract no such thing as a sacral torsion dys- 1) Ligamentous Laxity

This paper presents a conceptual function as such. . .it was all really 2) Multifidus somatic dysfunction
framework for the etiological factors just physical signs of loose ligaments. 3) Piriformis somatic dysfunction
that result in sacral somatic dysfunc- I have had some time to reflect and 4) Biceps femoris somatic
tions. The author points to the likely integrate the role of ligamentous lax- dysfunction
multi-etiological factors that result in ity into my conceptual understanding 5) Erector spinae somatic
sacral somatic dysfunctions. These fac- of sacral dysfunction. dysfunction
tors include ligamentous laxity of the This is quite different from the
sacroiliac articulation and somatic dys- explanation that I was provided in Iliacus Dysfunction
function of the multifidus, piriformis, medical school that conceptualized: First, let us discuss why an iliacus
erector spinae and biceps femoris “…as the patient walks forward the dysfunction doesn’t cause a sacral
muscles. The most important factors center of gravity shifts from side to torsion and should never be mistaken
seem to be the ligamentous laxity and side and is over the stance limb at for one by the distinguishing osteo-
the multifidus somatic dysfunction. De- about the cranial limb of the sacro- pathic physician. It is necessary to
finitive diagnosis of the etiological fac- iliac joint. At the middle of the stance understand how this faux paw arrived
tors of sacral somatic dysfunctions is and swing phases the swing side iliac in the literature. The assumption was
key to their treatment. Further study is crest is lower than the stance side and that a hypertonic iliacus would cause
obviously needed in this area. the lumbar spine has a curvature con- the ilium and the rest of the
vex on the swing side. As the swing hemipelvis to rotate anteriorly around
continues the sacrum moves about an
Introduction the sacrum. This would result in the
oblique axis the superior end of which findings on palpatory examination of
Recently, I had the unfortunate ex-
is on the stance side. As the walk shallow sacral sulci on one side and
perience of being asked a question
continues the alternate oblique axis consequently a deep one on the other
about a topic in which my mind was
is involved. It is postulated that at side. However, upon performing a
changing. The topic was sacral tor-
some point within the walk, or trunk seated flexion test these findings
sions. The reason for the change was
movement standing still, the contin- would most likely disappear since the
I had recently attended the AAO
ued alteration of the oblique axes is iliacus would be put in a position of
sponsored course, Prolotherapy: Be-
restrained and asymmetry appears at relative rest. This is exactly why we
low the Diaphragm and read The AAO
rest.”2 perform a seated flexion test. . .to
Journal article on “iliacus dysfunc-
This was acceptable for a naïve identify anomalous findings!
tion”.1 However, I was motivated
medical student, but is no longer ac-
from the challenge of changing my
ceptable as a physician with patients
perceptions of a problem to explore
that depend on you for pain relief.
Ligamentous Laxity
and consequently benefit my patients Next let us examine the theory of
Naïveté aside, I now realize that there
in more definitive treatment. ligamentous laxity. According to this
are several aspects to a sacral dys-
According to my colleagues teach- theory, ligamentous laxity of the SI
function. These include:
ing the prolotherapy course there was
➻

Spring 2003 The AAO Journal/23

(sacroiliac) articulation cause reflexic Multifidus Muscle
myofascial tightening and this con-
Somatic Dysfunction
sequently locks the hypermobile joint
Multifidus hypertonicity/spasm is
into a guarded position to achieve sta-
a likely part of sacral torsion. It is a
bility. This is a very plausible and a
very large muscle extending the en-
probable culprit in the formation of
tire length of the spinal column (see
sacral somatic dysfunction. However,
Figure 1). Since our concern is mostly
unlike many of the proponents of this
the lumbosacral portion of it that will
theory, I believe that not everyone
be our focus. Its fibers actually origi-
with a sacral somatic dysfunction
nate on either side of the sacrum sur-
needs prolotherapy.
rounding the 1st through 3rd sacral fo-
Ligaments given the proper cir-
ramina (see Figure 2) and the mam-
cumstances will heal. None other than
millary processes of L5 to T12 verte-
William Garner Sutherland pioneered
bra. 2,3 As its name indicates the
balanced ligamentous tension tech-
muscle is divided into many bundles
nique. In this technique muscles and
of muscle fibers. The bundles of mul-
fascia are given the chance to func-
tifidus fibers pass 2 to 5 vertebral seg- Figure 1 The Multifidus Muscle: The
tion properly by aligning the joint and
ments and then insert medially and bundles of fibers pass 2 to 5 vertebral
its surrounding tissues along vectors
above near the base of a vertebral segments and insert medially and
that result in a state of mechanical
spinous process and laterally and be- above near the base of the spinous
balance. This mechanical balance
low to the transverse processes.4 They processes & laterally and below to
also allows the nervous system to
have even been found to insert upon the transverse processes and even the
achieve a more settled state and di-
the posterior capsule of the lumbar posterior capsule of the lumbar facet
minishes facilitation, The conse-
facet joints.5 joints. From Grant’s Atlas Images -
quence of this newly balanced joint
Pain from the multifidus muscle Complete Collection. Williams &
is diminished ligamentous strain, di-
group can present in many different Wilkins, A Waverly Company. 1998:
minished facilitation, and healing of
ways. Travell, et al describes severe BUL07007
the ligament.
aching “bone” pain that can be per-
For instance, a 16-year-old gentle-
sistent, worrisome and disabling.4
man presented to my office with right
The attachment to the posterior cap-
knee pain 6 months after his original
sules of the facets can result in a
basketball injury. He had been taken
tensioning, effect on the capsule.5
for exploratory knee arthroscopy and
Multifidus trigger points located from
the minor tears in his medial menis-
the lumbar vertebra level may project
cus were trimmed. Upon examination
pain anteriorly to the abdomen, which
he clearly had ligamentous laxity
may be mistaken for a visceral nature.
upon a valgus stress placed upon the
Multifidus trigger points at the level
right medial collateral ligament. He
of S1 project pain downward toward
was treated with balanced ligamen-
the coccyx and result in hypersensi-
tous tension technique and acupunc-
tivity of the coccyx. This condition
ture every 1 to 2 weeks. After 2.5
is often identified as coccygodynia.4
months of treatment along with glu-
It is easy to hypothesize that depend-
cosamine sulfate (1500 mg a day) and Figure 2 - Muscle Insertions Upon
ing on which fibers originating on the
a multivitamin the ligamentous laxity the Sacrum: Fibers originate on the
sacrum are involved may dictate which
resolved. This example demonstrates sacrum surrounding the first through
type of sacral somatic dysfunction a
the ability of ligaments to heal when third sacral foramina. Modified from
patient has. Deep fiber hypertonicity
motion, nutrition and qi are restored in Manual Medicine 2. Williams &
of the multifidus unilaterally is likely
an otherwise healthy young man. Wilkins, A Waverly Company. 1997:
to cause the sacral base to be restricted
MM211016
anteriorly resulting in a unilateral sac-
ral flexion or forward torsion on the
ipsilateral side. Superficial or full thick-
ness fiber hypertonicity of the multifi-

24/The AAO Journal Spring 2003

dus unilaterally is likely to cause the
sacral base to be restricted posteriorly
resulting in a backward sacral torsion
on the ipsilateral side.
Clinically, since recognizing the
association between sacral somatic
dysfunctions and multifidus hyperto-
nicity, I have yet to find a patient in
which the multifidus did not play a
role. In addition, it is very easy to rec-
ognize that in every osteopathic treat-
ment imaginable for sacral somatic
dysfunction we are addressing this deep
rotator of the lumbar spine. Further- Figure 3 - The Pirformis Muscle: Originates on the anterior
more, I have found that isolating the aspect of the ILA of the sacrum and inserts upon the medial
multifidus for trigger point injection or side of the superior aspect of the greater trochanter. From
more often for dry needling the patient Manual Medicine 2. Williams & Wilkins, A Waverly Company.
responds far more favorably than with 1997: MM206023
OMT alone. Multifidus somatic dys-
function and backward sacral torsion
seems to have a near 100% concurrence
of occurring together.

The Piriformis Somatic

Dysfunction
The piriformis has long been
thought the major muscular culprit in
sacral torsions. It is often singled out
in manipulation textbooks as the tar-
get of treatment in muscle energy for
sacral torsions.1,6,10 The piriformis
originates on the anterior aspect of the Figure 4 - The Pirformis Muscle Trigger Points and Referred Pain Pattern:
inferior lateral angle (ILA) of the Pain is referred to the sacroiliac region, to the buttock, posteriorly over the hip
sacrum and inserts upon the medial joint and may also extend upward in the posterior thigh as high as the crease
side of the superior aspect of the of the buttock. From Manual Medicine 2. Williams & Wilkins, A Waverly
greater trochanter (see Figure 3). 7 Company. 1997: MM209010
Trigger points from the piriformis
refer pain to the sacroiliac region, to
the buttock, posteriorly over the hip
joint, and to the proximal two-thirds
of the posterior thigh (see Figure 4).
Hypertonicity of it, theoretically,
may create the diagonal axis of rota-
tion for the sacrum. Therefore, a hy-
pertonic right piriformis causes a left
axis and vice versa. As a result of this
association I had tried to use
counterstrain, dry needling and even
trigger point injection to address this
Figure 5: The Biceps Femoris and the Sacrotuberous Ligament Continuity:
muscular component of sacral tor-
Seen here from the lateral aspect one can appreciate the continuity between the
sions. However, after searching for
tendon of the biceps femoris muscle and the sacrotuberous ligament. From
trigger points in this muscle, I had
Manual Medicine 2. Williams & Wilkins, A Waverly Company. 1997: MM211005
Spring 2003 The AAO Journal/25
 frequently been disappointed to not
find a 100% association. Even when
present I did not have the experience
of it being a cure all for the back pain
associated with a severe backward
sacral torsion.

Long Head of the

Biceps Femoris and
the Sacrotuberous
Ligament
Originating from the posterior as-
pect of the ischial tuberosity is the
long head of the biceps femoris
muscle. It inserts upon the lateral as-
pect of the fibular head.9 The signifi-
cance of this muscle is that it there is
probably a fascial continuity with the
sacrotuberous ligament (see Figure
Figure 6 - The Erector Spinae Muscle Group: Originating partially from the 5). This ligament attaches from the
heavy tendons that surround and interdigitate with the origin of the multifidus inferior lateral angle of the sacrum,
and having a broad insertion. From Manual Medicine 2. Williams & Wilkins, and runs to the ischial tuberosity.
A Waverly Company. 1997: MM201019 The pain pattern of the trigger
points from the biceps femoris is to
the back of the knee. Spillover referred
pain extends downward a short distance
below the knee into the calf and may
also extend upward in the posterior
thigh as high as the crease of the but-
tock.9 Recognizing this fascial conti-
nuity often helps to understand the sci-
atic pain associated with sacral torsions
and imbalance between the sacrotuber-
ous ligamentous laxity.8

Erector Spinae Muscle

Somatic Dysfunction
The erector spinae muscles origi-
nate partially from the heavy tendons
that surround and interdigitate with
origin of the multifidus (see Figure
1).2 It has a broad insertion that is
Figure 7 - Trigger Points & Pain Referral Pattern of the Iliocostalis Lumborum beyond the scope of this article to
& the Longissimus Thoracis: The iliocostalis lumborum refers pain from the elaborate upon. It is composed prin-
upper lumbar area concentrating downward to the midbuttock. The longissimus cipally of 3 muscles with several parts
thoracis T10 & T11 trigger points refers pain strongly to the low buttocks and and we are going to discuss only the
at the L1 level will refer just lateral to the high buttocks just lateral to the PSIS. iliocostalis lumborum and the long-
From Manual Medicine 2. Williams & Wilkins, A Waverly Company. 1997: issimus thoracics (see Figure 6). The
MM204002 & MM204006 iliocostalis lumborum trigger point
pain pattern may refer pain from the

26/The AAO Journal Spring 2003

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Sacral somatic dysfunction is an Manual Volume 1. Upper Half of Body. by F. P. Millard, DO
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interesting topic whose treatment and
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theory and tradition. I believe that this 5. Loeser, John D., Joseph M. Czerniecki,
article may at least begin some Barry Goldstein. Bonica’s Management of by Percy H. Woodall, MD, DO
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ONLY $19.95
anchor”. Without its proper function Spinal Manipulation - fifth edition.
many osteopaths, including myself, Butterworth Heinemann: London, En-
gland: 1992; 154-156 __________________________
believe that the musculoskeletal sys- Name (please print)
tem would be prone to imbalance, 7. Travell, Janet G., David G Simons. Travell
somatic dysfunction, pain, and the & Simons’ Myofascial Pain and Dysfunc- ___________________________
possible impact upon the other organs tion: The Trigger Point Manual Volume
2. The Lower Extremities. Williams &
Street Address
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Wilkins. Baltimore, MD: 1992; 186-214
Since research in the cause and __________________________
effect relationship of somatic dys- 8. Ward, Robert C. Foundations for Osteo- City, State, Zip
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__________________________
outcomes studies and evidence-based Daytime Phone
9. Travell, Janet G., David G Simons. Travell
medicine. It would be particularly & Simons’ Myofascial Pain and Dysfunc-
interesting to see if other physicians tion: The Trigger Point Manual Volume
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MasterCard or VISA
between sacral somatic dysfunction
and multifidus somatic dysfunction. 10. Janiak, Daniel D. Review of Sacral So- __________________________
Also, it is interesting to note that the matic Dysfunction. The AAO Journal.
piriformis somatic dysfunction is not 11:1, 19-23
__________________________
as frequently associated with sacral Card Number
somatic dysfunction as would be ex-
pected. I have not been looking at Address correspondence to: __________________________
connection between the sacrotuber- Jay B. Danto, DO Expiration Date
ous ligament and the biceps femoris ABODE Integrated Medicine, PLLC
to make any judgment as to its in- 6450 Farmington Road, #121 __________________________
volvement, but theoretically there West Bloomfield, MI 48322 Signature
should be either involvement of the Phone: 248/788-3956
sacrotuberous ligament and/or the Fax: 248/788-3983
piriformis in nearly all sacral torsions. E-mail: jbdanto@aol.com Item No. WPCD03

Spring 2003 The AAO Journal/27