Root Cause of Sacral Torsion, Sacral Shear, and Anterior Sacral Tilt

Reports show that low back pain is the leading cause for disability worldwide and one of the most common reasons for visits to the doctor.¹ Statistically, up to 40% of low back surgeries fail.² Data further demonstrate that almost 50% of individuals with chronic pain have considered suicide.³ When conservative treatment for low back pain, such as medication, massage, chiropractic and physical therapy, do not relieve a person’s back pain, more invasive treatments (eg, surgery or interventional procedures) may be considered. These options, however, can sometimes lead to permanent complications and ongoing pain. Misalignments of the sacrum as well sacral torsion and sacral shear are less commonly determined reasons for low back and buttock pain (descriptions of these conditions are provided below). Although sacral torsion and sacral shear have been known to the medical community for decades, the author was unable to find scholarly publications detailing the exact cause of these conditions or how often they present clinically. However, the author evaluates and treats hundreds of these patients a year in his clinic and appears to have identified the root cause of sacral torsion and sacral shear as being a simple piriformis strength asymmetry causing a sacral rotation and subsequent sacral shearing at the lumbosacral junction. Less commonly, hyperlordosis of the lumbar spine results in an anterior tilt of the sacrum causing the sacral shearing, or both. Herein, the author describes his clinical experience, along with a retrospective patient review, in assessing and treating sacral torsion, sacral shear, and anterior sacral tilt.

Orthopedic evaluation of the sacrum can be complex as it moves on multiple axes: transverse, vertical, anterior/posterior, and oblique.⁵ Current evaluation methods, generally taught in physical therapy and chiropractic schools, to determine sacral torsion and sacral shear can be difficult as multiple bony and ligamentous landmarks and positions need to be assessed to make an accurate diagnosis. The two core tests that are often recommended to diagnose the position of the sacrum are the Sphinx Test and seated flexion test.⁶ ⁷ The following landmarks are typically recommended to be palpated and assessed:

• bilateral deep sacral sulcus

• bilateral inferior lateral angles of the sacrum (ILA)

• position of anterior superior iliac spine of the pelvic innominate

• position of posterior superior iliac spine of the pelvic innominate

• pubic symphysis

• position of L5 vertebrae

• laxity or tension on the sacrotuberous ligament⁵

Once the practitioner obtains the position of these landmarks, the sacral positioning can be assessed. The practitioner needs to assess whether the sacrum is positioned:

• right on right forward sacral torsion or rotation

• left on left forward sacral torsion or rotation

• right on left backward sacral torsion or rotation

• left on right backward sacral torsion or rotation

• unilateral sacral flexion

• ·unilateral sacral extension

• bilateral sacral flexion

• bilateral sacral extension⁶

Sacral Torsion Signs & Symptoms

The diagnosis of sacral torsion is typically made based on history and physical exam.5 Often, sacral torsions can be caused by physically traumatic events such as falls, childbirth, motor vehicle accidents, stepping off a curb wrong, or other trauma.⁴ However, in the author’s clinical experience, sacral dysfunctions can also develop without a traumatic event.

Normally, people with sacral torsion experience pain around the piriformis origin at the lateral border of the sacrum that is typically described as buttock pain and may be diagnosed as a piriformis spasm and/or buttock pain from sciatica.⁸ People with sacral torsion pain typically report pain with sitting and/or standing, flexion and/or extension as well as lying supine or side lying.

Sacral Shear Signs & Symptoms

A diagnosis of sacral shear is typically made from history and physical exam.⁴ The cause of sacral shear, in the author’s experience, is often caused by either sacral torsion or an anterior tilt of the sacrum, and less commonly it can be caused by both. Sacral shear pain is typically described as being present around the base of the sacrum at the L5/S1 region; it may be referred superiorly into the lumbar spine or described as an “achiness” across the low back, as well as referred pain into the sacrum itself.

Varying movements tend to exacerbate sacral shear pain. Patients often report their symptoms are exacerbated while sitting on certain surfaces. They also report pain when standing. Performing standing lumbar extension is the most common aggravating motion in the author’s experience, and, in less common cases, standing lumbar flexion causes pain. Patients typically describe the pain as “sharp,” “stabbing,” or “pinching,” as it is mechanical bone on bone shearing pain. Most people describe very severe debilitating pain with both sacral torsion and shear, with difficulties performing even basic activities of daily living such as standing, walking, sleeping, standing, sitting, working, and household chores.

Existing with sacral torsion and sacral shear is almost always concurrent sacroiliac joint dysfunction (see prior paper outlining the root cause of sacroiliac joint dysfunction with an effective simple four-step exercise protocol and diagnostic procedure for SI joint dysfunction).⁹ The SI joint assessment procedure also allows the practitioner to immediately identify if the numbness, weakness, and/or pain in the low back, hip, groin, or leg is caused by SI joint referred pain or by another injury by realignment of the upslip and/or gapping open the SI joint creating an inflare of the innominate. If the symptoms are immediately relieved, the etiology of those symptoms is confirmed to be SI joint.⁹

Proposed Diagnostic Procedure for Sacral Torsion and Sacral Shear

Locating multiple sacral landmark positions in conventional teachings can lead to misdiagnosis. The author has identified easier and more effective diagnostic procedures for both sacral torsion and sacral shear where the torsion is causing the sacral shear and a sacral shear that is caused by an anterior tilt of the sacrum. Conventional teachings state multiple lumbar and sacral landmark positions need to be assessed to diagnose sacral positioning and misalignment.6 In the author’s method, when diagnosing sacral torsion, the only landmark and sacral position that needs to be assessed is the positioning of the bilateral inferior lateral angles of the sacrum.

Evaluation of the patient can be done in the prone position with the practitioner placing the thumbs on the bilateral inferior lateral angles of the sacrum (see Figures 1, 2). The patient should be instructed to keep the gluteus maximus muscles relaxed and perform a prone press up test (see Figure 3).¹⁰ It is imperative that the gluteus maximus muscles do not engage as the practitioner will not be able to accurately assess the position of the inferior lateral angles of the sacrum. The practitioner is looking for which thumb “drops” or moves toward the anterior aspect of the body. It is not necessary to ascertain the position/alignment of the base of the sacrum, or any other sacral landmark or lumbar spine position, in order to successfully diagnose and stabilize the sacrum into the correct position in this evaluation method and treatment protocol, making it easier to diagnose and successfully rehabilitate the patient than conventional teachings.

Locating which thumb “drops” or moves toward the anterior aspect of the body will reveal which piriformis is weaker. If the left thumb drops or moves toward the anterior aspect of the body when the practitioner assesses the position of the ILAs, the patient will have a strength asymmetry of the piriformis with the right piriformis being weaker than the left (see Figure 4) If the practitioner’s right thumb drops or translates toward the anterior aspect of the body, a manual muscle test of the piriformis will typically reveal a weaker left piriformis versus the right side.

Evidence of a sacral shear caused by an anterior tilt of the sacrum can be determined by applying anterior and inferior force at the inferior aspect of the sacrum with a simultaneous prone press up test. If this mobilization immediately relieves the pinching or sharp pain at the L5/S1 region, this confirms the diagnosis of anterior sacral tilt (see Figures 5a, 5b). Definitive diagnostic confirmation of a sacral torsion and sacral shear caused by the torsion can easily be made when the sacrum is realigned, the patient performs the aggravating motion, and the pain/symptoms are immediately relieved.

Confirmation of the etiology of the buttock and/or low back pain that is caused by the sacral torsion and/or sacral shear can be achieved with realignment of the sacral torsion if the sacral shear is caused by the torsion. Once the practitioner assesses which thumb drops or which ILA of the sacrum translates toward the anterior aspect of the body, the practitioner can apply pressure to the ILA opposite of the side that drops. The pressure should be applied at an inferior and lateral force in the direction of the inferior aspect of the greater trochanter.

To obtain a proper realignment, it is important to apply an inferior traction force as well as lateral as to not “jam” the base of the sacrum at the L5/S1 junction. If the left thumb drops or translates toward the anterior aspect of the body with the prone press up test, the practitioner applies a firm lateral and inferior force to the right ILA for approximately one minute to attempt to realign the sacrum into neutral anatomical positioning (see Figure 6). The patient should be asked to perform the aggravating motion again, which is typically the prone press up test again and the position of the ILAs are reassessed. If the pain was eliminated in the low back or buttock, the diagnosis of a sacral torsion and/or shear has been confirmed. If the patient reports their pain is still present after attempted realignment, the practitioner should attempt the same realignment procedure again with more force and may want to hold the pressure longer than one minute at the ILA. Also, the practitioner can apply the pressure to the ILA and have the patient perform a simultaneous prone press up test as well. These steps will also provide immediate confirmation that a sacral torsion and/or shear is present if immediate relief is achieved.

Realignment of the sacral torsion using inferior and lateral pressure to the ILA that does not result in complete relief of low back and/or buttock symptoms establishes the low back and buttock pain is not solely caused by the torsion. The next assessment should focus on anterior tilt of the sacrum. The patient can be asked to perform the prone press up test, which will typically reproduce the symptoms. The practitioner will apply pressure inferiorly and anteriorly (toward the anterior aspect of the body) to the inferior aspect of the sacrum creating a “gapping” at the L5/S1 junction (refer to Figures 5a, 5b) The pressure is best applied while the patient performs a simultaneous prone press up test. If immediate relief is achieved, a diagnosis of anterior sacral tilt is causing the sacral shearing is confirmed.

Of the different exercise protocols delineated herein, the exercise protocol for sacral torsion and sacral shear caused by the torsion is the same. There is, however, a different protocol recommended for sacral shear caused solely by an anterior sacral tilt (more on this below). The practitioner assesses the position of the inferior lateral angles of the sacrum. If the practitioner’s left thumb drops or translates toward the anterior aspect of the body, the right piriformis is to be strengthened. If the practitioner’s right thumb drops or translates toward the anterior aspect of the body, the left piriformis is to be strengthened. The protocol is meant to be performed unilaterally with seated piriformis strengthening using a resistance band (see Figures 7a, 7b). The patient should be instructed to perform one to five sets of 30 reps on the opposite side of the thumb that drops or translates anteriorly, progressing from one set up to five sets if possible as the piriformis gains strength. The protocol should be performed until the pain is eliminated. The author typically recommends a red or green band.

Most sacral shear pain is caused by a sacral torsion only, however, when sacral shear is present solely due to an anterior tilt of the sacrum there is almost always a hyperlordosis of the lumbar spine present, causing the shearing at the lumbosacral junction, in the author’s experience. The hyperlordosis can be addressed by performing single and double knee to chest exercises, stretching the bilateral hip flexors, strengthening the bilateral hamstrings with standing hamstring curls, creating a posterior pelvic tilt and reducing the lordosis, which creates space at the lumbosacral junction (see Figures 8-11). The author typically recommends 10-pound sand weights for standing hamstring curls each leg. (Of note: the author uses this same protocol to treat the central protrusion type of herniated discs of the lumbar spine, as creating a posterior pelvic tilt opens up the central lumbar canal creating space for the nervous system.) Using this protocol for anterior sacral tilt and central protrusions may take 6 to 8 weeks on average to start noticing a reduction in symptoms. The author does not recommend or use this protocol for posterior/lateral herniated discs. For posterior/lateral herniated discs, the author recommends focusing on gently and carefully stretching the bilateral piriformis muscles with the focus on achieving knee to opposite shoulder which often takes months. The practitioner should advise the patient not to stretch too aggressively as this may increase nerve tension and exacerbate sciatic or other nervous system symptoms.

Achieving the desired clinical outcome for sacral torsion and shear generally can only be accomplished with the patient resting during the treatment course, with no extraneous activity, to allow for the sacrum to stabilize. Instructing patients to perform the following protocols in pain-free range of motion two to three times a day until symptoms are eliminated is recommended. It is also important to educate patients about not putting themselves in pain in any way while performing the exercises to avoid further exacerbation of symptoms and prolonging the rehabilitation process.

Sacral Torsion and Sacral Shear Exercise Protocol (when caused by Sacral Torsion)

• Seated unilateral piriformis strengthening with red or green band 1 to 5 sets of 30 reps, 2 to 3 times a day (see Figures 7a, 7b)

Sacral Shear and Central Protrusion Type of Herniated Disc Exercise Protocol (when caused solely by Anterior Tilt of Sacrum)

• Standing hip flexor stretch bilaterally 3 x 30 seconds, 2 to 3 times a day (see Figure 10)

• Standing hamstring curls with weight (typically 10 lbs sand weight on each leg) 1 to 5 sets of 30 reps, 2 to 3 times a day (see Figure 11)

• Single knee to chest 3 x 30 seconds each side, 2 to 3 times a day (see Figure 8)

• Double knee to chest 3 x 30 seconds, 2 to 3 times a day (see Figure 9)

Gains of full range of motion and total reduction of pain were achieved in 19 patients with sacral torsion caused by sacral shear. All patients, from the author’s clinic, were able achieve a negative prone press-up test and all reported no pain with lumbar extension, flexion, side lying, sitting, and/or standing. All 19 were followed up after treatment course; 18 were able to be reached and reported no pain or restriction in activity. Those 18 further reported being able to complete all activities and independent activities of daily living without any complaints of pain within the prior 12 weeks. Five patients reported exacerbations of symptoms after their successful rehabilitation; when those 5 continued the prescribed exercise protocol (2 to 3 times a day), they were able to regain a pain-free state.

Nineteen patients experienced complete low back and/or buttock pain relief immediately after realignment of the sacral rotation and/or anterior tilt, confirming the etiology of their pain as being mechanical in nature.