Lumbar, Pelvic and Sacroiliac Set Ups

The lumbar spine and pelvis are where most practical exam candidates feel at home, and that comfort is exactly where points leak away: a side posture set up done from habit, with no screening question, no consent, a vague contact and a line of drive that does not match the listing. This chapter rebuilds the lumbar, pelvic, sacroiliac and coccygeal set ups as station performances, so that every step you take on the table is one an examiner can see, hear and score. The same discipline protects real patients, because the low back is also where the dangerous mimics (cauda equina syndrome, aneurysm, fracture, metastasis) hide.

Section 1Lumbar side posture set ups

What the technique station is really scoring

Practical technique stations of this kind generally present a door card with a short history, a listing or a set of findings, and a task such as "demonstrate the set up for this listing and verbalize as you go." The thrust itself is usually not delivered on a standardized patient; you take the set up to tension and describe the thrust. Examiners therefore score what they can observe: whether you introduced yourself, confirmed identity, screened for contraindications, obtained consent, positioned the patient safely and modestly, located the correct segment, took the correct contact, stabilized properly, set the line of drive that matches the listing, and said all of this aloud. Check the current official candidate materials for exactly what is scored and whether any thrust is allowed; never assume.

Every set up in this chapter has six parts: listing, patient position, doctor stance, contact point and segmental contact, stabilization, and line of drive. Name all six aloud, in that order, and you will rarely miss a scored element.

The universal opening for any lumbopelvic station

Side posture positioning: building the lock

Side posture (often called the lumbar roll position) places the patient on one side with the segment to be adjusted positioned so that rotational and flexion tension localize at that level. The positioning is the same for every lumbar side posture variant; only the contact and the side the patient lies on change.

1. Choose the side. For the mammillary push and the spinous pull, the patient lies with the side of posterior body rotation up. Because listings are named by the direction the spinous process has moved, the posterior body side is opposite the spinous direction: a spinous rotated right (body rotated left, left side posterior) is set up with the patient lying on the right side, left side up.
2. Bottom leg straight, top leg flexed. The down leg stays extended in line with the trunk. The up hip and knee flex, and the up foot rests in or just behind the popliteal fossa of the down leg.
3. Flex to the level. Monitor the interspinous space of the target segment with one hand while you flex the top hip with the other. When the space just begins to open at the target, stop: flexion has reached that level. More flexion moves tension higher; less leaves it lower.
4. Rotate from above. Draw the down arm and shoulder gently toward you (or ask the patient to reach the down hand toward the ceiling end of the table), so the upper trunk rotates back. Tension from above now meets tension from below at the segment.
5. Stance. Stand facing the patient in a split (fencer) stance, cephalad foot forward. Place your caudal thigh against the patient's flexed top knee, so your leg can roll the pelvis toward you and contribute to the thrust.
6. Stabilize. Your cephalad hand rests on the patient's up shoulder or the anterior deltoid and pectoral region, holding the trunk counter rotation. It does not push hard; it maintains the lock.
7. Take the contact with your caudal hand (see below), take out the remaining slack by rolling the patient slightly toward you, and set the line of drive.

The thrust in a lumbar side posture adjustment is a short, shallow impulse delivered by a body drop: the doctor's trunk drops through the contact arm while the thigh on the patient's knee drops toward the floor and the stabilizing hand holds the shoulder. A long, forceful rotation of the whole patient is not the goal; specificity comes from the lock, not from amplitude.

The three side posture variants

The mammillary push uses a pisiform (hypothenar) contact on the mammillary process of the up side, which is the side of posterior body rotation. The line of drive is posterior to anterior, following the plane of the lumbar facets, which are oriented close to the sagittal plane in the upper lumbar spine and turn more toward the coronal plane at L5 and S1. Because the push is on the posterior side of the body, it rotates the vertebral body back toward neutral and carries the spinous process back toward the midline.

The spinous pull contacts the down side of the spinous process with the fingertips or the pads of the middle and ring fingers (reinforced by the other fingers), and the thrust pulls the spinous process toward the ceiling, that is, back toward the midline. The patient lies with the spinous laterality side down, which is the same side choice as the mammillary push. The pull is often chosen when the patient is large, when the up side mammillary is too tender to contact, or when the doctor wants to emphasize rotation over posterior to anterior glide.

A spinous push (used in some systems) contacts the up side of the spinous process and pushes it away, so the side the patient lies on reverses. Use the variant your program teaches; the examiner scores internal consistency of side, contact and line of drive with the listing.

The general lumbar roll or pelvic roll uses a broad contact (forearm or hand over the posterior ilium or upper buttock) and a rotational body drop without segmental specificity. It is useful for general mobilization of the lower lumbar and sacroiliac region, for large patients and as a teaching foundation. It is less specific and should not be presented as a segmental correction for a named listing.

Safety inside the set up

Lumbar side posture manipulation has a very low rate of serious adverse events, but the events that do occur cluster in predictable patients. Do not thrust in side posture in suspected cauda equina syndrome (saddle anesthesia, new urinary retention or incontinence, bilateral or progressive leg weakness), which is an emergency referral; in suspected fracture after significant trauma or minor trauma in an older or osteoporotic patient; in known or suspected malignancy involving the spine; in infection (fever, intravenous drug use, recent procedure); with a pulsatile abdominal mass or known abdominal aortic aneurysm; or with progressive neurologic deficit. Relative cautions that change the method rather than forbid care include osteoporosis, anticoagulation, acute disc herniation with severe antalgia, spondylolisthesis and recent surgery.

If the patient reports sharp leg pain, new numbness or a sense of the leg "going dead" as you take the lock, stop, release the tension slowly, return the patient to a neutral comfortable position, reassess neurologic status (dermatomes, myotomes, reflexes, straight leg raise) and change approach. Say this sequence out loud on a station: it is a scored safety behavior.

Section 2Lumbar prone and flexion distraction options

When side posture is not the right tool

Side posture is efficient, but it combines rotation, flexion and a thrust, and some patients tolerate none of those well. A candidate who recognizes this and switches methods earns credit for clinical judgment; a candidate who adjusts every lumbar listing in side posture loses it. The common reasons to choose another approach are listed below, along with the usual substitute.

Prone lumbar set ups

Prone lumbar techniques place the patient face down on a table with a face piece, arms at the sides or on arm rests, and a pillow under the abdomen if the patient's lordosis is large or extension is painful. The doctor stands on the side that suits the contact, usually in a fencer stance facing cephalad or at right angles to the table.

• Prone unilateral mammillary or transverse contact. Pisiform on the mammillary process of the posterior body side; stabilizing hand over the contact wrist (reinforced) or on the opposite side of the pelvis. Line of drive posterior to anterior with a slight lateral to medial component, delivered as a short thrust from a locked elbow and body drop.
• Prone spinous contact. Pisiform on the side of the spinous process, pushing it toward the midline (lateral to medial with a posterior to anterior component). Used when rotation is the main component.
• Bilateral thenar or "butterfly" contact. Thenars over both mammillary or transverse regions, used for an extension restriction (segment fixed in flexion); line of drive posterior to anterior. Avoid in spondylolisthesis and in painful extension.
• Drop table (Thompson style). The lumbar or pelvic drop piece is raised and its tension set just high enough to hold the patient's weight. The doctor takes the contact, pre loads lightly, and delivers a fast, shallow thrust that releases the drop piece; the abrupt stop of the piece completes the impulse. Drop reduces the force needed and is very comfortable, which makes it a common choice for older patients.

Prone thrusts load the abdomen and lower ribs, so ask about abdominal pain, recent abdominal surgery, pregnancy and any pulsing abdominal sensation first.

Flexion distraction

Flexion distraction (often taught as the Cox method) uses a table whose caudal section hinges downward and can also move laterally and in circumduction. The patient lies prone with the hips over the hinge, ankles secured in cuffs. The doctor stands at the patient's side, contacts the spinous process of the segment above the involved disc with the hypothenar (for an L4/L5 disc, the contact is on the L4 spinous), and slowly lowers the caudal section with the other hand. The contact hand holds the upper vertebra while the table draws the lower segments into flexion and long axis distraction, opening the posterior disc space and the intervertebral foramen.

The essential safety step is the tolerance test. Before the full procedure, the doctor applies a gentle contact and a small amount of flexion and asks whether leg pain changes. If radicular pain increases or peripheralizes (travels farther down the leg), the procedure is stopped and the patient is reassessed. If pain stays the same or centralizes (retreats toward the back), the treatment proceeds. Treatment for disc lesions is given as slow, gentle distractions in short sets, typically a few repetitions held for a few seconds each and repeated in two or three sets, never pushed to pain. Lateral flexion and circumduction motions are generally reserved for facet syndromes and for discs that are already improving, because they add load to the annulus.

Instrument and low force options

Handheld adjusting instruments and graded mobilization suit osteoporotic, anxious, pediatric and frail patients. The set up still has a listing, a contact (the instrument tip on the mammillary, spinous or lamina), a stabilization and a line of drive, and an instrument never excuses skipping screening, consent or verbalization.

Section 3Pelvic and sacroiliac listings

Why the ilium gets its own vocabulary

The sacroiliac joint moves only a few degrees. Listing systems describe the ilium relative to the sacrum by where the posterior superior iliac spine (PSIS) has moved. Because the ilium rotates about an axis near S2, a change at the PSIS implies predictable changes at the ischial tuberosity and acetabulum, and therefore at leg length. Stations give you one or two of these findings and ask for the listing and the correction.

Ilium listings

Listings are often combined, such as PI EX or AS IN; these pairings are the most frequently taught because the shape of the joint couples posterior rotation with external rotation and anterior rotation with internal rotation. The National (motion) system describes the same lesions as restrictions: a PI ilium behaves as a restriction of anterior rotation (flexion of the ilium), and an AS ilium as a restriction of posterior rotation. Know both vocabularies and translate aloud when a door card uses the one you did not train in.

Sacral listings

The sacrum is listed relative to the ilia (or to L5, depending on the system). The commonly taught descriptions are:

• Base posterior on one side (Gonstead style P R or P L): the sacrum has rotated so one side of the base is posterior; the sacral base on that side palpates prominent and the sulcus shallow. Corrected with a contact on the posterior side of the base, line of drive posterior to anterior.
• Base posterior bilaterally (sacral base posterior, sacral extension in motion terms): reduced lumbosacral lordosis, deep sacral apex. Corrected with a contact at the base, posterior to anterior.
• Base anterior (sacral flexion): increased lumbosacral angle; corrected with a contact near the apex, posterior to anterior and inferior to superior, or by an approach that lifts the base.
• Sacral torsions (in osteopathic and motion terminology): rotation about an oblique axis, named as forward torsion (left on left, right on right) or backward torsion (right on left, left on right). On a chiropractic station, translate a torsion into which side of the base is posterior and which inferior lateral angle is posterior, then choose the contact.

Confirming a pelvic lesion: the examination cluster

No single sacroiliac test is reliable on its own. Stations reward a cluster approach, and you should be able to name and briefly perform the usual pieces:

A commonly taught rule is that three or more positive pain provocation tests out of the five (distraction, compression, thigh thrust, Gaenslen, sacral thrust) increase the likelihood that the sacroiliac joint is the pain source, particularly if lumbar centralization has been ruled out.

Section 4Sacroiliac and sacral set ups

Side posture ilium corrections

Side posture for the ilium uses the same general positioning as the lumbar set up, with three important differences. First, the involved ilium is up. Second, the lock is taken lower: the top hip is flexed more for an AS correction (often to about 90 degrees, so the ischium is accessible and the ilium can be rotated posteriorly) and less for a PI correction (so the PSIS faces the doctor and the ilium can be rotated anteriorly). Third, the trunk rotation is lighter, because the goal is to isolate the sacroiliac joint rather than a lumbar segment.

• PI ilium. Pisiform contact on the PSIS (for PI EX, on the medial aspect of the PSIS; for PI IN, on its lateral aspect). Doctor's thigh on the top knee. Line of drive posterior to anterior and inferior to superior, with a medial to lateral component for EX or a lateral to medial component for IN, delivered by a body drop. The elbow of the contact arm is lowered so that the forearm points along the I to S line.
• AS ilium. Pisiform or hypothenar contact on the ischial tuberosity, with the top hip flexed further. Line of drive posterior to anterior, with a slight inferior to superior component as commonly taught, which rotates the ilium posteriorly about the sacral axis. Care with modesty: explain before you touch, contact over the gown or drape, and use a broad, firm hand rather than fingertips.
• IN or EX alone. Contact on the lateral (IN) or medial (EX) side of the PSIS or the posterior iliac crest, line of drive across the joint (lateral to medial or medial to lateral) with a posterior to anterior component.

Prone and drop corrections for the ilium

Prone pelvic adjustments are comfortable, quick and easy to verbalize, and drop tables reduce force. The patient lies prone, the pelvic drop piece is raised, and its tension set to the patient's weight. The doctor stands on the side opposite the involved ilium for a PSIS contact reached across the body, or on the same side, depending on the system taught.

• PI on a drop table. Pisiform on the PSIS of the involved side; line of drive posterior to anterior and inferior to superior; a short, fast thrust releases the drop.
• AS on a drop table. Contact on the ischial tuberosity (some programs teach this with the patient's knee flexed and a block or with a modified approach); line of drive posterior to anterior.

Sacral set ups

Sacral contacts are made over the sacral base (just medial to the PSIS, over the first sacral tubercle region), the sacral body, or the apex. The commonly used set ups are:

Supine and other approaches

A supine sacroiliac approach uses the doctor's hand under the PSIS or sacrum as a fulcrum while force is applied down the flexed femur; muscle energy techniques (patient contraction against resistance, then taking up the new range) suit acute, anxious and pregnant patients.

Section 5Coccyx and pelvic special cases

Coccyx: listings, screening and external technique

Coccydynia is pain at the coccyx, usually worse on sitting and on rising from sitting, often after a fall onto the buttocks, after childbirth, or with prolonged sitting on hard surfaces. The coccyx is most often found flexed (anterior) after a fall, sometimes deviated laterally, and occasionally hypermobile. Dynamic sitting and standing lateral radiographs can show abnormal flexion, extension or subluxation, and are considered when symptoms persist.

Screening comes first. Fracture after a recent fall, a pilonidal cyst (tender, swollen, sometimes draining skin over the sacrococcygeal region), a perianal abscess, rectal or pelvic disease, and sacral tumors such as chordoma (slowly progressive pain, constipation, a presacral mass) can all present as tailbone pain. Night pain, weight loss, rectal bleeding, change in bowel habit or a palpable mass warrant referral.

External technique is the default and the only approach appropriate to demonstrate on a standardized patient. The patient lies prone with a pillow under the pelvis. The doctor explains exactly where the contact will be, offers a chaperone, and uses a drape. Contacts include a light thumb or pisiform contact on the sacrococcygeal junction or on the lateral border of the coccyx through the drape, with a gentle sustained pressure or a low force impulse in the direction that reduces the listing (for an anterior coccyx, a gentle lift of the sacral apex combined with release of the gluteal and pelvic floor soft tissues). Soft tissue work to the gluteus maximus, the sacrotuberous ligament and the coccygeus region, cushion advice (a wedge or cutout cushion) and sitting posture advice are part of the plan.

Internal (per rectum) coccygeal techniques exist, but whether they are within scope depends on the jurisdiction. They require specific, documented informed consent, a chaperone, gloves and lubricant, and a clear clinical reason. On a practical exam, do not perform or simulate an internal approach; state that you would use external technique, and that internal technique would require scope verification, specific written consent and a chaperone.

Pregnancy

Pregnancy brings increasing lumbar lordosis, an anterior shift in the center of mass, and ligament laxity (related to relaxin and other hormones), and low back and pelvic girdle pain are very common. Manual care is widely used and generally well tolerated when it is modified.

• Positioning. Use side lying with pillows between the knees and under the abdomen, or a pregnancy table or cushions that allow prone positioning without abdominal pressure. Avoid prolonged supine lying in later pregnancy, which can compress the inferior vena cava and cause dizziness and hypotension; tilt the patient to the left side if supine work is needed.
• Force. Use lower force and less amplitude. Laxity means less force is needed and that hypermobile joints (especially the symphysis pubis and the sacroiliac joints) should not be pushed to end range.
• Side posture. Reduce lumbar rotation and hip flexion, and keep the abdomen supported. Drop table and instrument methods are useful.

Red flags in pregnancy require immediate obstetric referral and no manipulation: vaginal bleeding, leakage of fluid, regular painful contractions before term, severe or constant abdominal pain, reduced fetal movement, and signs of preeclampsia (new hypertension, severe headache, visual disturbance, right upper quadrant or epigastric pain, sudden swelling of face or hands). Calf pain and swelling in pregnancy or postpartum must be treated as a possible deep vein thrombosis.

Osteoporosis and the older patient

Osteoporosis is a reason to change the method, not necessarily to withhold care. Risk factors to ask about include female sex and menopause, age, low body weight, long term corticosteroid use, smoking, heavy alcohol use, previous fragility fracture, rheumatoid arthritis, and a family history of hip fracture. A sudden onset of thoracolumbar pain after minimal stress in such a patient is a compression fracture until proven otherwise. Avoid rotational side posture thrusts and heavy prone posterior to anterior thrusts in significant osteoporosis; choose drop with minimal tension, instruments, flexion distraction, mobilization, soft tissue work and exercise.

Other modifications to know

Words worth knowing