Force

Force

A — Posterior Sacral Base

P — Posterior InferiorLateral Angle

D — Deep Sacral Sulcus

Fig. 2

Sacral shear:Review and a new treatment method

for obstetrical patientsby Robert C. Treadwell, UTF and Warren W. Magnus, UTF

University of North Texas Health Science CenterTexas College of Osteopathic Medicine

IntroductionSacral shear is a common diagnosis

in the general population and isassociated with back pain that is oftenunresponsive to other treatments,including lumbar spinal manipulation.The obstetrical patient suffers fromparticular susceptibility to thisphenomenon and poses unique treatmentdifficulties for the osteopathic physicianin clinical practice.

Sacral Shear (Definition)According to Kuchera, "a sacral shear

is a nonphysiologic motion of a sacroiliacjoint produced by opposite forces, onesuperior and the other inferior, at thesacroiliac articulation." The superiorforce occurs through the innominatefrom the ischial tuberosity or from thehip articulation at the acetabulum. Theinferior is the weight of the trunkdelivered through the spine at the SIjoint (Fig. 1).

These forces can be brought the bearon the SI joint through a variety ofmeans, but is generally traumatic inorigin. Often the patient history willinclude a fall on the gluteal area, asurprise step off of a curb or into a hole,or other trauma that would induceunilateral forces at the SI joint. This is asimilar phenomenon to that whichcreates the superior innominate shear,but the force vectors are localized to theSI as opposed to distributed upwardsthrough the innominate.

Fig. 1

Symptomatology can vary fromunilateral SI joint pain, often describedby the patient as "hip pain," to diffusepain resulting from the sacral unlevelingthat the shear creates.

Sacral Shear (Findings)Sacral shearing creates unique

findings that are often dramatic.Innominate motion may be reducedbilaterally and pelvic compressiontesting may be equivocal.

Palpation of the inferior lateral angles(ILAs) of the sacrum often reveals amarkedly inferior ILA on the side of theshear. Static findings are the diagnostickeys. The inferior ILA on the side of theshear is usually posterior and the sacralbase is usually anterior on the side of theshear creating a deep sacral sulcus - (Fig.2). Even in cases of marginal ILA

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Fig. 4

inferiority, the motion testing of thesacrum will show significantly reducedmotion at all poles.

Sacral shears are identified based onthe involved side, the side of the inferiorILA. Thus, a low ILA on the left wouldbe identified as a left sacral shear.Kimberly further identifies the shear asunilateral, so the left shear becomes a"left unilateral sacral shear."

Obstetrical considerationsThe obstetrical patient has unique

considerations that both make the patientmore prone to sacral shearing as well ascomplicating treatment. As pregnancyprogresses, ligaments throughout thebody, but particularly in the pelvisbecome lax in preparation forparturition. This phenomenon resultsin an environment in which a sacralshear can occur with relatively mildtrauma, such that the patient's historyoften does not reveal the source of thesacral shear.

A dysfunctional sacrum subsequentlyplaces undue strain on the ligaments ofthe pelvis and surrounding musculatureleading to multiple complications. Theseinclude low back pain and pelvic pain.The tightening of the pelvic musclesthat results can restrict fluid drainagefrom the lower limb through the pelvicdiaphragm resulting in edema andvenous insufficiency.

Treatmentof the sacral shear

Kuchera and Kimberly both describemultiple techniques for the treatment ofsacral shear, but all of their describedtechniques are difficult if not impossibleto perform in the third trimester. Pronetechniques are complicated by thepresence of the gravid uterus, makingpatient comfort as well as uterinecompression concerns. Supine techniquesmay also be complicated by compressionof the abdominal vasculature by aparticularly large gravid uterus.

A lateral recumbent technique isdetailed by Kuchera. Unfortunately, this

Fig. 3

method requires one operator to stabilizethe ILA on the sheared side and anotheroperator to provide a high velocity-lowamplitude tug to the patient's leg on thesheared side to reduce the sacral shear.This tug technique may cause a strain ofthe knee ligaments which are alreadyloose secondary to relax in in theobstetrical patient.

A new techniqueTo treat a sacral shear in a lateral

recumbent position, the patient is

positioned with the sheared side up.Both legs are flexed to provide stabilityto the patient and promote patientcomfort. The operator is seated behindand facing the patient on a stool. Theoperator utilizes their caudal hand toraise the patient's leg on the side of theshear and then stabilizes the leg byplacing their elbow on the table (Fig. 3).The operator then places their cephaladhand on the sheared ILA, contacting itinteriorly (Fig. 4). The patient is askedto press downward against the operator's

Spring 1996

AAO Journal/17

Supportersof the

1996 Annual ConvocationAmerican Academy of

Osteopathy

American Anatomical Corp.Bayer Pharmaceuticals

Central Pharmaceuticals, Inc.CCOM

Cranial AcademyCuratek PharmaceuticalsDaniels PharmaceuticalsHorizon PharmaceuticalsJanssen Pharmaceutica

Juice Plus/Guy DeFeo, DOKnoll Pharmaceuticals

National Osteo. FoundationOMM Recruiting

OPTPOsteopathy's Promise to Children

PCOMStronglite Table Company

Thera Cane Co.Wallace Laboratories

Wyeth-Ayerst LaboratoriesHerbert Yates, DO, FAAO

in addition to the above list,each school will have an

Undergraduate Academy booth.

Letter to the Editor

hand with the raised leg. As the SI jointgaps from the muscular force, theoperator provides a springing forcecephalad through the inferior ILA. Thisprocedure can be repeated as needed toreduce the sacral shear.

Follow-upSacral shears with successful

treatment rarely recur. The mostcommon cause of recurrent sacral shearsis a long-standing shear, which hasstretched the supporting ligaments.

Dear Sir,I am writing to commend the

American Academy of Osteopathy forco-sponsoring the recent SecondInterdisciplinary World Congress onLow Back Pain held in San Diego.

As osteopathic physicians, thediagnosis and treatment of low backpain, specifically involving the lumbarspine and sacroiliac joints, are our "breadand butter." The osteopathic professionhas been at the forefront of diagnosisand treatment for somatic dysfunctionof these areas, but there is significantresearch, outside the osteopathicprofession, both in the basic sciencesand clinical management of disorders ofthe sacroiliac joint.

There is no dispute that the treatmentof low back pain, particularly involvingmanual techniques, requires significantart as well as science. Research is onlynow documenting motion anddysfunction involving the sacroiliacjoints, which we as clinicains have knownfor a long time. Scientific study may,however, provide additionalunderstanding of this system differentthan the interpretation arrived byclinicians practicing the art of manual

Pregnant patients with unusualligamentous laxity may repeatedly sheartheir sacra and require repeated treatmentthroughout the pregnancy. Patientsshould be reexamined a week followinginitial treatment of a sacral shear toverify both treatment success and toevaluate pelvic stability.

ReferencesI . Kuchera, Wm. A., DO, FAAO, and Kuchera.Michael L., DO, FAAO: Osteopathic Principlesin Practice. Second Edition-Revised, Columbus,OH, Greyden Press, 1994, pp463-470

medicine. For that reason, I do feel thatit is important for the osteopathicprofession to continue supportingresearch, not only to validatemanipulative treatment, but also tocontinue to lead to better understandingof the scientific basis for manualmedicine.

I think that we in the osteopathicprofession sometimes overlook thecontributions to manual medicine byother physicians, both in this countryand abroad. I personally was impressedto see the AAO President-elect, Dr.Kuchera, on the program with otherreknowned researchers including Drs.Vleeming, Mooney, Gracovetsky,among others. It is very healthy forosteopathic researchers to communicatewith other researchers who may approachthe lumbar and sacroiliac regions from asurgical or medical standpoint. Ourinterpretation of the data may differ, butthat will lead to better understanding anddevelopment of both the science and artof manual medicine in the future.

Sincerely,Charles H. Cummings, DO

2. Kimberly, Paul E., DO: Outline ofOsteopathic Manipulative Procedures. ThirdEdition. Kirksville, MO, Kirksville College ofOsteopathic Medicine, 1980, pp79-80

3. Scott. James R., MD; DiSalsa, Philip J. MD;Hammond, Charles B., MD; Spellacy, WilliamN., MD: Danforth's Obstetrics and Gynecology,Sixth Edition. Philadelphia, JB LippincottCompany, 1990, pp98

4. Kuchera, Wm. A., DO. FAAO: OsteopathicManipulative Management of the ObstetricalPatient, Kirksville, MO, FAAO Thesis, 1988

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