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Function and patomechanics of the sacroiliac joint: A review

Article in Physical Therapy · January 1985

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 The Cause of Acute and Chronic Low Back Pain as a
Reversible Pathology at the Sacral X Axes.

The relief of common low back pain is immediate with a manual force
bilaterally in posterior innominate rotation on the sacral x axis.
The Final Report on the DonTigny Method

A TECHNICAL TREATISE

(First Revision) November 22, 2017

Richard L. DonTigny, PT
Independent researcher
81 North Shore Drive #10
Belgrade, MT 59714
406-219-3416
rldpt@thelowback.com

I am the sole author. This is my discovery, my research, my illustrations and my

biomechanics. The manuscript submitted does not contain information about medical
devices or drugs. No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related directly or indirectly
to the author of this manuscript. This represents over 50 years of investigation and
research on over 8,000 patients in the area of idiopathic low back pain. © DonTigny

Key Words
Sacral X axes, force couples, balanced ligaments, pelvic biomechanics, biotensegrity of
gait, sacroiliac pathology, immediate relief of common low back pain.

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Abstract

In the last century much research was accomplished on the pelvis yet the function of the
pelvis remains an enigma. Many practitioners suspect the pelvis to be the source of
common low back pain, but just as many practitioners believe this not to be true.

Ten years ago two separate axis points were located that looked like they could
function as bony transverse sacral X axes providing the pelvis was symmetrical,
however, if and when the pelvis is asymmetrical each point could also function with a
related pelvic point and act as an oblique axis. The resting pelvis is unmoving and
almost immobile, however, the erect and loaded pelvis is dynamic and filled with kinetic
energy.

Primary sacral loading is on the posterior interosseous ligaments and serves to

suspend the sacrum. Primary loading initiates a secondary loading on the
sacrotuberous ligaments that balances the primary loading. These two sets of balanced
ligaments create two sets of interactive force couples and a trigger for biotensegrity.

During normal gait an initial unilateral posterior innominate rotation on the side
of the first step causes the ilial tuberosity at the PSIS to push caudad directly on the
lateral sacrum causing a lateral sacral flexion with rotation. The trunk is caused to
counter rotate thus decreasing loading forces to the femoral head. When loading is
shifted to the contra lateral side on the second step the weight shift takes place with
biotensegrity mechanics. Movement is through balanced, interchangeable, parallel,
kinetically loaded ligaments that create interactive force couples. None of this was
possible to determine without the sacral x axes. This is all way beyond conventional
biomechanics.

Acute and chronic back pain is essentially all caused by an anterior rotation of
the bilateral symmetrical innominates (lifting, bending lowering, shoveling, sweeping, a
pendulous abdomen, pregnancy or a postural forward head) that causes the
innominates to rotate cephalad and laterally at the sacral PIIS usually one side more
than the other. This is a measurable movement that puts a vertical cephalic shear on
the lateral axis points and separates the sacral origins of both the gluteus maximus and
the piriformis from their ilial origins resulting pain in the buttocks, piriformis syndrome
and a pseudo-sciatica. Dysfunction is all initiated at the sacral x axes. This is corrected
effectively simply with a manual bilateral posterior innominate rotation that reverses all
symptoms leaving the patient free of pain.

2
Introduction

The complexity of sacral mechanics is awesome. Some of the things that have
confused many are that movement in the weight loaded pelvis is entirely different than
in the non-weight bearing pelvis; that loading of the sacrum is vastly different than
loading of the innominates; and that movement at the sacroiliac joints (SIJ) is
completely different than movement at any other joint. A possible oblique axis has been
suspected, but its location has not been identified. (1)

In 2007 two separate, rather obscure and commonly overlooked transverse

sacral X axis points were discovered at the posterior aspect of sacral S3.(2) These
axes work together as a common transverse axis when both innominates are
symmetrical or individually as oblique axes when the innominates are asymmetrical and
rotating in opposite directions. (2) Analysis of movement and function has been
relatively straight forward and relatively simplistic once these axes were identified.

Kinetic loading of balanced ligaments creates inter-acting oblique force couples

that drive counter rotation of the innominates when ambulating. Illustrations and x-rays
are used to help locate the sacral X axes, to demonstrate balanced ligamentous loading
and to illustrate their function as biotensegrity mechanics during normal gait. This has
not been previously possible to describe without the critical sacral X axes.

Figure 1. The sacral X axes lie snuggly and unobtrusive at the PIIS. The ilial tuberosities at the PSIS on
each side overlie the sacrum and push directly downward alternately on the sacrum to cause lateral
sacral flexion, which causes counter rotation and decreases loading forces to the femoral heads.

3
The Unloaded Symmetrical Pelvis Demonstrates No Sacral Movement.

Fig. 2. Vukicevic found that in normal standing, the sacroiliac joints can withstand a wide range of
loading without pelvic or sacral deformation even after the elimination of the sacrotuberous and
sacrospinous ligaments.(3) The joint surfaces do not approximate with this loading, however, these joints
become profoundly unstable after the removal of the posterior interosseous ligaments. Without
ligamentous restrictions, the super-incumbent weight causes the sacrum to tilt ventrally, essentially
unimpeded by structure. When there are no ligamentous restrictions, the structure of the joint allows it to
open.

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Dynamic Loading Of The Symmetrical Pelvis

Figure. 3. With loading the pelvis is symmetrical. The sacral x axes on each side work together as a
single transverse axis to allow the anterior sacrum to move caudad and the posterior sacrum to move
cephalad. Primary loading of the posterior ligaments causes the sacrum to rotate anteriorly on the sacral
x axis suspending the sacrum. Secondary sacral loading is tethered distally and limited by an equal force
on the sacrotuberous ligaments. The loading forces are thus stored bilaterally in a sacral float with a
kinetic loading.

5
Loading the Symmetrical Pelvis on the Acetabular Axis

When moving from a supine to an erect posture the super-incumbent weight is loaded
first on the sacrum, with primary loading on the posterior interosseous ligaments (F1).
The sacrum inclines ventrally on the sacral X axis with this loading causing a
simultaneous secondary loading dorsally on the sacrotuberous ligaments (F2). The
secondary sacral loading posterior and caudal to S3 balances the primary sacral
loading at S1. (F1 = F2) The primary loading force is constant after loading. The
secondary loading force is dependent upon, is directly related to, must equal and thus
balance the primary loading force.(2,4,5) (Figure 4,5)

The secondary loading forces below S3 (F2) must equal, but cannot exceed the
primary loading forces at S1 (F1). Therefore F1 = F2. Therefore F1 – F2 = 0. With
normal loading force closure is balanced and equals 0. With overloading (X Kg) F1 + X
= F2 + X. Therefore (F1 + X) – (F2 + X) = 0. Force closure must still equal 0. (2,4,5)
(Figure 5)

Figure 4. Primary loading from the line of gravity on the acetabular axis rotates the sacrum
anteriorly and the innominates posteriorly, reinforcing the primary loading . Note the location of the sacral
axis and the angle of the SIJ. Without the supporting posterior interosseous ligaments the sacrum
would tend to fall away from the innominates. Courtesy of the Journal of Prolotherapy © DonTigny

6
Thus the primary loading force (F1) and the secondary loading force (F2) are always in
balance. Any increase in weight carrying will increase both primary and secondary
loading equally. Thus the closing force at the sacroiliac joints will be essentially nil. It
will be noted also that the sacrotuberous ligaments are slightly helical. During extremes
of motion helical coils improve dynamics, allow for greater elasticity, increased
movement and a greater storage of kinetic energy.

Figure 5. The lumbar lordosis is increased with the primary sacral loading, as is the lumbosacral
angle, but because the line of gravity is posterior to the acetabular axis, loading of the sacrum causes a
simultaneous, sequential, secondary loading of the pelvis resulting in a posterior innominate rotation on
the acetabular axis. The secondary loading of the innominates further loads and balances the ligaments,
decreases the lordosis and decreases the lumbosacral angle. Courtesy of the Journal of Prolotherapy ©
DonTigny

Opposing forces created when these ligaments are loaded create transient,
multiple, interchangeable force couples. The moments created by the force couples
create force-dependent transverse and oblique axes of rotation for the SIJs when the
sacrum is loaded. The secondary loading caudal to S3 must be strong enough to equal
the primary sacral loading at S1 in order to stabilize the ilial convexities in the sacral
concavities. These force couples modify, absorb and redirect forces such as linear and
angular acceleration and deceleration, linear and angular momentum, impact loading
and unloading and others. Force couples help to enhance function, preserve the
systems, and prevent injury.

7
 If the sacroiliac ligaments were removed and the subject moved from supine to
erect and loaded the sacrum, the sacrum will continue to incline ventrally. It will move
ventrally at S1 and because of the ilial tuberosity superior to S3, the caudal sacrum will
move dorsally on the sacral X axis. If it were not for the ligamentous restrictions, the
sacroiliac joints could not sustain weight loading. This is totally dependent upon the line
of gravity being posterior to the acetabular axis causing a posterior innominate rotation
which further balances kinetic tension on the posterior interosseous and sacrotuberous
ligaments. (Figures 4 & 5)

Movement of The Loaded Symmetrical Pelvis

Sacral movement that occurs during loading and unloading of the superincumbent
weight is not the same as the movement that occurs after the sacrum is loaded. After
loading, essentially no movement occurs on a transverse axis on the symmetrical pelvis
even though ligamentous tension will vary. Resting kinetic tension on both the posterior
interosseous and sacrotuberous ligaments is relatively high and balanced. (6) Posterior
rotation of both symmetrical innominates will increase tension on both the posterior
interosseous and sacrotuberous ligaments, decrease the lumbosacral angle, decrease
the lumbar lordosis and decrease shear at L5-S1. The SIJs are essentially non-weight
bearing joints with a balanced zero loading. Once the ligaments are loaded and
balanced, loading may be increased without causing further movement in the sacrum
because all loading is balanced and interdependent.

Some consensus was reached when several researchers found that the structure
of the SIJ was such that the sacrum hangs suspended from the ilia by the dense
posterior interosseous ligaments and when loaded with the superincumbent weight
hangs more deeply between the ilia. This is the reverse of a keystone. (10, 11, 12, 13)
Not reported or not known at that time was that this loading was superior and anterior to
an obscure and undescribed sacral X axis. An axis for asymmetric rotation of the
innominates is at the pubic symphysis while symmetric rotation of the innominate bones
is on axes through the acetabula. (2, 4, 5)

The Asymmetric Pelvis During Ambulation

Both Greenman (1) and Vleeming (14) noted that during the swing phase of the right
leg, the right innominate rotates posteriorly and pushes the sacrum downward at the
PSIS on an axis through the pubic symphysis. When the pelvis is oblique and
asymmetrical, the transverse sacral x axis changes to an oblique axis. The sacrum is
caused to flex laterally toward the side of loading.

8
Primary sacral loading on the sacral X axis increases lordosis, increases the
lumbosacral angle and causes the joint to separate. Primary pelvic loading with
posterior pelvic rotation decreases lordosis, decreases the lumbosacral angle and
balances the kinetic ligamentous loading. This prepares the pelvis for dynamic
movement.

Figure 6. Standing and Weight Loaded on a Transverse Acetabular Axis. Symmetrical

innominates. Weight Bearing is on the Femoral Heads.
A. Posterior innominate rotation on an acetabular axis. PSIS caudad. Lordosis decreased. Decreased
shear on lumbosacral joint. Lower iliac crest. Line of gravity is posterior to the acetabular axis reinforcing
the posterior innominate rotation. Kinetic energy is increased. Axis at symphysis not active.

B. Anterior innominate rotation on an acetabular axis. The sacral axis is raised relative to the acetabular
axis. PSIS cephalad. Lordosis increased. Increased shear on lumbosacral joint. Higher iliac crest. Line of
gravity is more anterior increasing anterior innominate rotation. Anterior innominate rotation puts a
vertical shear on the sacral x axis. Kinetic energy is decreased. Movement at the symphysis is only with
asymmetry, the oblique pelvis and movement on the sacral axes.

9
Figure 7. Posterior oblique pelvis From relaxed standing the first movement in normal gait is to flex the
knee initiating posterior rotation of that innominate bone to create a pelvic asymmetry. (1) Posterior
innominate rotation of the working innominate moving on an axis through the pubic symphysis depresses
the ilial tuberosity down on the posterior-lateral surface of the sacrum causing a lateral sacral flexion. (1)
Lateral sacral flexion creates an oblique sacral axis with an oblique force couple from S3 on the side of
loading to S1 on the off- loaded side. The sacrum rotates toward that off-loaded side and functions to
decrease loading on the femoral head.

Figure 8. The oblique sacral loading axis . Anterior Note the near vertical angulation of the sacroiliac
joints, how loading of the sacrum will tend to open this joint and how this is prevented from acting as the
keystone of an arch. Note the direction of sacral movement in lateral flexion.. Courtesy of the Journal of
Prolotherapy © DonTigny

10
 The innominate is forced into asymmetry and to flex laterally right or left with
posterior rotation, which initiates transient, alternating, oblique force couples. The
sacrum moves obliquely back and forth with the alternate changes in posterior
innominate rotation. The transverse S3 sacral X axis is functional only in the position of
the symmetrical pelvis at swing- through at the mid-step position when the loaded force
couple immediately shifts to the alternate, unloaded side.

At heel strike the sacrum is rotating anteriorly at S1 on the off-loaded side and
posteriorly at S3 on the side of loading, moving on S3-S1 oblique axis. (Figures 9-10)
Excess tension caused by loading forces on the oblique force couple increasing
posterior innominate rotation is accommodated in the helical sacrotuberous ligaments.
Forces decrease after loading and oblique force couples reverse instantly at mid-step
when the pelvis is briefly symmetrical and posterior innominate rotation is initiated on
the contra lateral side. This is a four-bar biotensegrity movement and is driven by
loaded kinetic ligaments. (www.biotensegrity.com)

Figure 9. From the symmetrical mid-step position, the ilial tuberosity of the innominate on the loading
(right) side flexes to create asymmetry and rotates the sacrum on an oblique axis. Kinetic forces in the
ligaments increase until impact and then reverse and decrease till mid step when the pelvis is again
symmetrical. The unloading (left) side begins to anteriorly rotate and decelerate the loading (right) side.
Kinetic loading is probably essentially equal when the pelvis is symmetrical at mid-step. © DonTigny

11
Figure 10. At impact on the left, the right (trailing leg) innominate begins posterior rotation at knee
flexion and lift off. At single leg support the right (trailing leg) passes the mid line and the pelvis is
momentarily symmetrical and moves to asymmetry as the kinetic forces and posterior rotation increase.
The loading (left side) innominate flexes and rotates the sacrum toward the left as the kinetic forces
increase until impact. The sacrum oscillates once with each impact, twice with each stride. © DonTigny

The motions can be demonstrated on x-ray with the x-ray at the front of the
oblique pelvis in the long straddle position. (Figure 11) This system of movement is
commonly overlooked probably because of its obscurity, size and complexity. There is a
vast variance in this movement system dependent on the individual length and speed of
stride, variance in pelvic flexibility, posture and ambulatory pattern. Functional
asymmetric posterior innominate rotation is essential to trigger biotensegrity mechanics.
The SIJs function as interdependent, self-compensating force couples with variable,
force-dependent, transverse and oblique axes of rotation.

This biotensegrity function is palpable with a subject on a treadmill. With a hand

on each side of the sacrum, place the tip of each index finger immediately caudad to
each ilial tuberosity (PSIS) and the tip of each thumb on each side of the coccyx. Have
the patient ambulate with a long straddle stride and the pelvis moving oblique to the line
of travel. The tip of the coccyx will flex laterally back and forth, crossing the midline with
each step. Functional asymmetric posterior innominate rotation probably enforces
biotensegrity mechanics by equalizing kinetic loading at mid-step.

12
Figure 11. X-rays taken from the front of an oblique pelvis in the long straddle position with counter
rotation and with loading to the right and to the left. Note the location of the transverse sacral loading axis
and the transient oblique axis. Note the posterior rotation of the PSIS and the angle of the sacrum.
Courtesy of the Journal of Prolotherapy © DonTigny

Sturesson’s research

About the only agreement among researchers concerning the pelvis and low back pain
has been a general acceptance of Sturesson’s work. (15, 16) Sturesson x-rayed small
titanium balls implanted in the pelvis, used an XYZ axis at the anterior point of the
sacral plateau and made precise measurements in various positions. His method was
well thought out, extremely accurate, and has been used on over 4,000 patients. He
concluded that range of motion in the pelvis is extremely limited in the long straddle
position.

In retrospect the choice of placement for Sturesson’s XYZ axis, of necessity, was
arbitrary, inappropriate and should have been at the bony transverse sacral X axes and
at each oblique X axis. Measurements made on an inappropriate XYZ axis have led to
inappropriate interpretation, inappropriate research, inappropriate results and

13
inappropriate treatment. When Sturesson measured movement in the long straddle
position he had the pelvis blocked to the front, which is the position of symmetry the
pelvis assumes during normal gait in the single support phase. As a result his
measurements of pelvic movement in the long straddle position were all made on
subjects placed in the position of a symmetrical pelvis. With the innominates
blocked, the sacrum cannot move.

click to enlarge
Figure 12. Sturesson had the subject with the direction of travel straight into the camera
and with the pelvis perpendicular. DonTigny ©

Sturesson did not have the pelvis in an oblique or asymmetrical position nor did he
include counter rotation. Although his measurements were extremely accurate in this
position he inadvertently measured only some slight movement on the symmetrical
pelvis rather than normal movement on the oblique pelvis with counter rotation.

The lack of knowledge of the sacral X axes, their location, obscurity, movement,
function and possible dysfunction has stalled research in the pelvis. The transverse
sacral X axes and the sacral oblique axes on each side are more accurate and telling
locations than the XYZ axis at the sacral plateau used by Sturesson (15, 16). The
discovery of these axes has allowed for the discovery of balanced ligaments, force
couples, normal gait and biotensegrity.

14
Figure 13. X-rays were taken of the subject in the long straddle position with loading on the right. The x-
ray on the left is with the pelvis as per Sturesson, with travel toward the front, no asymmetry and no
counter rotation. The one on the right is with the pelvis facing the x-ray, with the direction of travel oblique
to the x-ray, the pelvis is asymmetrical and with counter rotation to the right.

Conclusion: The unloaded sacrum does not demonstrate any movement. When
loaded, the sacrum demonstrates ample movement during normal ambulation
when the pelvis is asymmetrical, oblique to the line of travel and with counter
rotation to the right and left. DonTigny ©

15
Dysfunction On The Sacral X Axes

These few references and comments are offered as an overview to help researchers
comprehend the complexity of dysfunction caused by forces in anterior innominate
rotation on the sacral X axis. (Figure 14) Inclusion of the critical sacral X axis is
essential to the evaluation and management of dysfunction of the sacroiliac joint (SIJD).
Many articles on non-specific back pain have reported no changes with exercises, but
non-specific is non-scientific. You must treat the anterior innominate rotation on the
sacral X axis.

Figure 14. Anterior innominate rotation (AR) causes an alteration in leg length as the PSIS and SIJ (P)
rise relative to the acetabula (F) making the legs appear longer. A manual posterior innominate rotation
(PR) on each side will cause each leg to shorten and each PSIS to move caudad (36). Continue until the
leg length no longer shortens and relief will be immediate

Onset is commonly by an anterior shift in the line of gravity from lifting, bending,
lowering, shoveling, sweeping, a pendulous abdomen, pregnancy, or a postural forward
head. Low back pain affects so many patients because there are so many activities that
can cause this dysfunction in anterior innominate rotation..

As normal function of the sacrum involves transient oblique axes across the
sacrum so may dysfunction. Manual tests can give the impression of dysfunction in
anterior or posterior dysfunction or combinations thereof; however, because of the
proximity of the innominates to the sacrum at the ilial tuberosities, a dysfunction in
posterior rotation is not possible. Dysfunction at the sacral x axis must always be
treated bilaterally with a manual correction in posterior innominate rotation. (2,4,5)

16
 Figure 15. The active rectus femoris is essential to prevent excessive movement in anterior
innominate rotation and thus prevent dysfunction.

Figure 16. The sequence of the onset of dysfunction in anterior innominate rotation.

17
 Sequence of Dysfunction

In the absence of anterior pelvic support when the line of gravity moves anteriorly the
innominates will tend to rotate cephalad and laterally on the sacrum at S3 and caudad
and laterally on the sacrum at S1. The sacrotuberous ligament is loosened. The
ligamentous balance is disturbed and the innominate bone will subluxate cephalad and
laterally on the sacrum on an acetabular axis.

Figure 17. A vertical shear occurs at the sacral x axis as the innominates rotate anteriorly to the
acetabula with a shift of the line of gravity. The shear causes a separation of the sacral origin of both the
piriformis and the gluteus maximus from their innominate origns.

When the balanced ligament position is released with a force in anterior innominate
rotation it will result in a vertical shear of ilial S3 on the sacral S3 segment at the
PIIS. (Figure 1 and Figure 10 and 11) This painful point is always present with SIJD,
but is commonly overlooked. The PIIS is immediately lateral, caudal and deep to the
PSIS at the juncture between the ilial and the sacral origins of the piriformis and the
gluteus maximus. This is the cause of piriformis syndrome. The sacral origin of the
piriformis is separated from its ilial origin at the superior margin of the greater sciatic
notch. The sacral origin of the gluteus maximus is also separated from its ilial origin on
a line from just caudal to the PSIS, across the buttock, into the trochanter and down the
tensor fascia lata into the lateral knee. This may cause a pseudo-sciatica. Simply by
identifying this primary painful point at the PIIS the practitioner can make a positive
diagnosis of SIJD (4, 5).

18
Figure 18. When leaning forward to lift, the sacral origin of the gluteus maximus and the sacral origin
of the piriformis stabilize the sacrum. The dysfunction in anterior innominate rotation creates a vertical
shear that causes the sacral origins of the gluteus maximus to separate from their ilial origins on a painful
palpable line across the buttock to the trochanter and from there to the lateral capsule of the knee. Shear
on the ilial origin of the piriformis can cause piriformis syndrome and a pseudo sciatica. © by DonTigny

Robinson et al noted that Manipulation of the lower back and pelvic region has
been found to improve the symmetry of gait after treatment. (17) Bernard and Fortin
each found that the consideration of SIJD as a cause of non- specific back pain has
greatly improved their ability to diagnose and treat non-specific back pain. (18, 19)
Ducroquet et al noted a decrease of pelvic rotation in the horizontal plane in patients
with SIJD. (20) Grieve found that sacroiliac strains sometimes follow gynecological and
obstetrical operations. (21) Calguneri found ligamentous laxity to be a factor in back
pain and accompanies pregnancy in the last trimester and to a lesser degree during
menstruation and menopause. (22) Grieve found that movement abnormalities of the
SIJs and pubic joints are a common cause of persistent postpartum pain, and simple
mobilizing techniques localized to the SIJs are very effective in alleviating this pain. (23)
Sunderland and Bradley found that an anterior and downward rotation of the
innominates on the sacrum may stretch the spinal nerve roots, which in turn may cause

19
neurological changes or lancinating pain. (24)
Abdominal pain at Baer’s point is not uncommon. This point is on a line from the
umbilicus to the anterior superior iliac spine, two inches (5 cm) from the umbilicus.(25,
26, 27) I had a patient who suffered from abdominal pain at Baer’s point and LBP for
four years. She had both ovaries removed without relief. She was free of abdominal
pain and LBP immediately following a manual correction in posterior innominate
rotation.

Figure 19. Note the apparent subluxation in anterior innominate rotation at the left end of the sacral X
axis. (Courtesy of Mitoshi Fukushima MD PhD, Fukushima Orthopaedic Clinic, 13-9, 1-choume,
Kairouen, Saeki-ku, 731-5135 Hiroshima-shi, Japan.

Fukushima (Figure 19) found that subluxation of the suboccipital joint provokes
severe neck pain and that intra-capsular or pericapsular injection into the SIJ can give
immediate relief of the neck pain. (28) He recommended that therapy should be
initiated to the SIJ dysfunction to relieve neck pain.

I once received an email from a PT in Hong Kong who teaches incontinence

training there and who had been to my workshop. She stated that following posterior
innominate rotation for SIJD the patients no longer required treatment for incontinence.

Shaw reported on 1000 consecutive cases of low back pain. He used

changes in apparent leg length and movement of the pelvis from asymmetry to
symmetry to correctly identify and treat the anterior dysfunction of the sacroiliac joints.
(29) He found that 98% of all patients had at least some degree of SIJD and his
surgical incidence for herniated discs dropped to 0.2%. Shaw has been ignored. More
recently Borowsky and Fagen have suggested that SIJD is far more common than is

20
generally thought. (30)

Murakami et al compared periarticular and intraarticular injections for diagnosis

of dysfunction of the sacroiliac joint. (31) Using periarticular injections in 25 consecutive
patients with SIJ pain they found that it was effective in all patients. Yeoman reported
that sacroiliac arthritis was responsible for 36% of the cases of sciatica. (32)

Davis and Lentle used technetium-99m stannous pyrophosphate bone scanning with
quantitative sacroiliac scintigraphy in 50 female patients with idiopathic low back pain
syndrome and found that 22 patients (44%) had sacroiliitis. Eight of these patients
(36%) had unilateral sacroiliitis and 14 (64%) had bilateral sacroiliitis. Of the 22 patients
with abnormal scans, 20 had normal radiographs. (33)

Timgren and Soinila found a reversible pelvic asymmetry, assessed the prevalence of
reversible pelvic obliquity and its subgroups among a given population and the results of
medical intervention. (34) Reversible pelvic obliquity proved to be unexpectedly
common in 554 (98,4 %) cases and symmetry could be re-established in all but one
case. Two manifestations of pelvic obliquity were iliac upslip and anterior rotation. The
former caused seeming shortening of the leg and compensating scoliosis convex to side
of the upslip and the latter seeming lengthening of the leg and a compensating scoliosis
with contralateral convexity. In the follow-up visit, 78% of the patients reported
improvement that was either significant or moderate in their functional ability and
reduction of pain. A strong correlation exists between the maintenance of symmetry and
the alleviation of the symptoms.(34A)

21
Figure 20. Direct effects of the subluxation of the sacral x axis at S3.

22
Figure 21. A single biomechanical lesion causes a multitude of pathological problems.

Conclusions

During normal ambulation the sacral X axes serve as a reservoir of kinetic energy and
function to enhance the forces of loading and unloading during normal gait through
balanced biotensegrity mechanics. Posterior innominate rotation causes the ilial
tuberosity at the PSIS on the loading side to cause the sacrum to flex laterally and
rotate. Oblique force couples distribute the loading through active kinetic ligaments to
decrease loading to the femoral head. The sacrum functions as a biotensegrity unit
during normal gait. Any dysfunction in anterior innominate rotation will alter these
mechanics.

Dysfunction only occurs when the line of gravity moves anterior to the acetabular
axis with lifting, bending, lowering, pregnancy, obesity, lumbar lordosis or forward head
posture and all can cause anterior rotation of the innominates on the sacrum. Anterior
innominate rotation occurs on an acetabular axis, increases the lumbosacral angle,
increases apparent leg length (usually bilaterally), increases shear at L5-S1, increases

23
the lordotic posture, and tends to decrease tension on the sacrotuberous ligaments and
iliolumbar ligaments. The PSIS of the ilial tuberosities lay immediately cephalad to the
sacrum and normally only respond functionally to gravity and posterior innominate
rotation. (Figure 1) The complexity of this multi-axial joint is only vulnerable to a
dysfunction in anterior innominate rotation.

Corrective exercises in manual posterior innominate rotation are very basic,

simplistic and immediately effective. Correction of this dysfunction causes a
measurable movement caudad and medially of the PSIS on the sacrum (35). Patients
do not usually require professional assistance. There is no danger in overcorrection
because of the bony blockage of the corrective posterior innominate rotation at the PSIS
by the sacrum. In all likelihood there is probably no other structures in the pelvis that
have been more frequently misunderstood, overlooked and neglected in the past
hundred years than the critical sacral X axes to the detriment of essentially all research
on low back pain and the pelvis.

. As the PSIS moves cephalad and laterally on the sacrum with a dysfunction in
anterior innominate rotation, thus so must the PIIS also move. All related pain is
immediately relieved with a manual correction of the sacral X axis in posterior
innominate rotation. White stated in 1982 that: “It may well be that idiopathic backache
will be found to be caused by some condition that is a subtle normal. Otherwise, we
probably would have found the cause already. If back pain were caused by a highly
unusual condition, then fewer people would suffer from this disorder.(36)” This is that
hidden and long searched for cause of acute and chronic low back pain, the
anterior innominate rotation stress on the sacral x axes

ADDENDUM
TESTING FOR SIJD

The Passive Straight Leg Raising Test (PSLR)

The PSLR test is commonly used to test for leg pain and sciatic neuritis. If lifting the straight
leg causes leg pain that is then increased with dorsiflexion of the foot (Laseques test) a
sciatic neuritis is indicated. However this test may also be used to determine SIJD.

With SIJD the PSLR test may actually decrease back pain because the pull on the
hamstrings with PSLR will cause the innominate bone to rotate posteriorly (backward). PSLR
may also increase pain in the low back on the contra lateral (opposite) side. As the pelvic
bone rotates posteriorly on the same side it will carry the sacrum back on the opposite
innominate and in effect cause a strain in anterior rotation on that side.

24
If PSLR increases pain on the same side (usually the side of the shorter leg) it is a sign
of a secondary slipping at S1 on that side. This is clinically insignificant but is treated by
many as a posterior innominate rotation or an upslip. Some chiropractors and PTs
mobilize this joint in an attempt to correct a posterior dysfunction or an upslip with the
patient side-lying, pulling back on the shoulder and shoving forward and down on the
pelvis. The lumbar spine is already unstable because of the loose iliolumbar ligaments
and the anterior rotation has overstretched the long posterior ligament. This incorrect
procedure could tear the annulus, rupture or extrude the disk, tear or avulse the long
posterior ligament and cause permanent chronic low back pain. THE PRIMARY
LESION IS AT S3 AND IS ALWAYS IN ANTERIOR INNOMINATE ROTATION. THE
ONLY CORRECTION NECESSARY IS OF A MANUAL BILATERAL POSTERIOR
INNNOMINATE ROTATION.

Leg Shortening Test

As the dysfunction in anterior rotation always causes the legs to get longer, sometimes
one more than the other, a manual rotation of the innominate bones on the sacrum will
cause each leg to appear to get shorter. This shortening of an apparent long leg is a
positive sign that has the advantage of correcting the dysfunction.

First stand at the foot of the plinth, grasp both ankles holding a thumb immediately
caudad to each medial malleolus (ankle bone) and approximate the ankles in the mid-
line. Check the leg length. Now it does not matter if the leg length appears to be even,
or longer on the more painful side or shorter on the more painful side. Lift either leg to
about 45 degrees of PSLR and traction it in the long axis hard enough to lift the buttock
on that side. This will cause the PSIS to move caudad on the sacrum. If dysfunction is
present, each leg will get shorter with flexion of each innominate on the sacrum. If they
are even, one leg will about 1cm shorter after testing. If you pull on the long leg, the legs
will probably appear to be of equal length. If you pull on the short leg at about 45
degrees of PSLR, it will appear to get shorter and may appear to be from 1-3 cm shorter
than the other.

Continue correcting with various described corrections gradually increasing pressure in

posterior innominate rotation. Do not stop when the legs appear to be of equal
length, but only after the legs no longer appear to get any shorter.

Injections
The primary points of pain are at the PSIS and PIIS and are extra-articular. If there
are no tears in the capsule the injection will become encapsulated and a
diagnostic injection may give a false negative result. Murakami et al (J Ortho
Science May 2007) in comparing periarticular and intraarticular injections for sacroiliac
joint pain injected periarticular lidocaine in 25 consecutive patients with SIJD and found

25
that it was effective in ALL patients. Intraarticular injections were effective in 9 of 25
patients. An additional 16 patients who had no relief from the initial intraarticular
injection were ALL relieved from a periarticular injection.

X-rays

In 1978 Davis and Lentle used technitium 99M stannous pyrophosphate bone scanning
with quantitative sacroiliac scintigraphy in 50 female patients with LBPS. They reported
that 22 patients (44%) had sacroiliitis. Eight of these (36%) had unilateral sacroiliitis and
14 (64) had bilateral sacroiliitis. Of the 22 patients with abnormal scans, 20 had
normal radiographs (Lancet 2:496-497, 1978)

Conventional X-rays have not demonstrated this dysfunction thus complicating

conventional evaluation and treatment. Referrals to psychiatrists are not helpful and the
patient frequently seeks unconventional care. Scanning of the lumbar spine does not
usually include the SIJs. When scanning, look for longitudinal tearing in the piriformis
muscle at the posterior inferior iliac spine. Arthrography of the SIJ may demonstrate
tears in the capsules, especially at or near the PIIS.

click to enlarge

26
 click to enlarge

Figure 22. Roentgenograms taken before (Above) and after (Below) correction of SIJD reveal a
dysfunction of the innominate bone cephalad and laterally on the sacrum. Note movement of the PSISs
relative to the sacral foramina.

Incidence
Shaw did a study of 1000 consecutive cases of idiopathic low back pain. Using objective
changes in leg length and changes in the pelvis from asymmetry to symmetry as guides
he found an incidence of 98% with SIJD contributing. His surgical incidence for
herniated disk dropped to 0.2%. (Reported in First World Congress on Low Back Pain
and the Sacroiliac Joint 1992)

Clinical Basis For Treatment

Corrective Exercises

As with the subluxation/dislocation of any joint, the first priority is to reduce the
subluxation. If it tends to recur the patient can be taught to self-correct. If the lesion is
unstable, a lumbosacral support or invasive procedures may be necessary.

Dysfunction of the sacroiliac joint is essentially always a pathological release of the

balanced position with an anterior rotation of the innominate bones on the sacrum.
Treatment is simply restoring the innominates back to the balanced position. It does not
matter if one leg appears to be longer or shorter on the more painful side of if they
appear to be of equal length, they will each always appear to shorten with correction of

27
the SIJ to the balanced position. If there is no history of a congenital leg length
difference, polio or serious leg fracture the legs will appear to be of equal length after
correction.

The corrections should be done every 2-3 hours all day long for at least three days to
take the tension off of the tight ligaments and give them an opportunity to recover. After
that correct at any sign of recurrence.

Nature of the Correction

The corrective procedure is not a vertebral manipulation. No high or low speed
manipulative thrust is necessary or indicated. No jerking or popping is necessary or
desirable. Correction is achieved by specifically applied traction on the properly
positioned joint or by a precise manual rotation of the innominate bones posteriorly on
the sacrum.

Manual Correction of the S3 Subluxation

Any of several methods can be used to restore the SIJ to the balanced position: traction
at about 45 degrees of PSLR; direct posterior rotation of the innominates on the
sacrum; or by using isometric or muscle energy techniques.

Traction correction with straight leg Traction correction on flexed leg in

will pull the PSIS caudad on the sacrum the event of an injured ankle.

Figure 23. Traction must be strong enough to lift the buttock on that side and
held for several seconds.

When distracting the leg have the patient lift his/her head and tighten the abdominal muscles to enhance
the posterior pelvic rotation. The rectus abdominis is most important to support posterior innominate
rotation when standing….NOT the transverse abdominis.

28
First do one side and then the other, checking the leg length at the malleoli and watch for shortening. Do
each leg, one at a time 4-5 times on each side, alternating sides each time and checking leg length each
time. The movement of the PSIS caudad on the sacrum can be palpated.

Do not pull on the leg in a direct line with the body.

back to top

THE EZ FIX
For a correction on the right side, put your left forearm under
the right knee and your left hand over the front of the left knee.
Push off with your left foot to provide traction, pulling on the leg
with the left forearm. The left hand will help to lever the traction.
Put just enough force on the right ankle with your right hand to
hold the knee in flexion. Apply enough traction to lift the buttock
on that side. Do each side 3-4 times, alternating sides each
time. To enhance the correction have the patient lift his/her
head to tighten the abdominal muscles. The tight SIJ acts like a
stuck drawer and gives just a little bit at a time on each side.

Figure 24

SELF-TRACTION SUPINE
The patient can use traction for self-correction by pushing the
thigh toward the foot hard enough to lift the buttock on that side.
Lifting the head at the same time will enlist the abdominal
muscles. Repeat several times on each side alternating sides
each time.

Do especially when you go to bed a night.

Figure 25

29
SEATED PATIENT CORRECTION may be done while at a
desk or in a car. Push one knee out. Pull the other knee back
firmly to pull the pelvis down in back. Tighten your abdominal
muscles to pull the pelvis up in front. Do several times on each
side alternating each time. Repeat several times daily.

Figure 26

STANDING PATIENT CORRECTION

Tighten abdominal muscles and push the knee toward the floor.
Repeat on the other side. Alternate exercise several times on
each side. Repeat correction several times during the day.

Figure 27

30
DIRECT CORRECTION (Two methods)
1. In the direct correction the leg can be used as a lever and
brought to the outside of the body. Knee to axilla. Put one hand
under the ischial tuberosity and the other on the top of the
patient's knee. While lifting with the lower hand, push downward
on the shaft of the femur while also rotating the thigh into
flexion.

2. The operator can also directly rotate the pelvis posteriorly by

placing one hand under the ischial tuberosity and the other over
the posterior aspect of the iliac crest. Rotate firmly pushing with
the thenar eminence.

Figure 28

DIRECT PATIENT CORRECTION

The patient can self-correct any time during the day no matter
what position he happens to be in at the time. Just by pulling
the knee into the axilla or bringing the axilla down to the knee.
Stretch firmly several times on each side, alternating sides each
time.

When doing any of these exercises in the supine position be

certain to hold your abdominal muscles tight when raising or
lowering your leg to prevent anterior rotation of the pelvis.

Figure 29

31
FLANK STRETCH
Following the direct correction a stretch of the quadratus
lumborum and the hip abductors can be helpful in achieving
further correction.

Stretch gently as indicated then have patient lift his leg against
resistance and then relax.

Take up the slack and put traction on the leg as indicated. This
may necessitate the aid of an assistant. Follow this with a hard
isometric correction.

Figure 30

ISOMETRIC CORRECTION
Grasp the knee with both arms, hold firmly and
push very hard outward with the knee. Be sure to
tighten the abdominal muscles while pushing with
the knee to enhance posterior rotation of the
pelvis and when lowering your leg.

A six-foot luggage belt may be used for

resistance or the patient can stand in a door
frame and push as shown. This is a very
powerful correction. Push hard and hold for
several seconds each time.

Figure 31

32
STRETCHING THE CORE MUSCLES ON THE
ASYMMETRIC PELVIS
As the core muscles are most active during
normal gait when the pelvis is asymmetrical, they
are most effectively stretched when the pelvis is
asymmetrical. Seated, project one thigh and
retract the other to create an asymmetric pelvis.
Flex and twist your trunk toward the side of the
retracted thigh. This stretches the piriformis, the
sacral origin of the gluteus maximus, the
quadratus lumborum, the multifidus, the
abdominal obliques, the latissimus dorsi and
others. Repeat toward the other side.

ALWAYS DO CORRECTIVE EXERCISES

BEFORE AND AFTER THESE STRETCHES.

Figure. 32

STRENGTHENING THE CORE ON THE

ASYMMETRIC PELVIS USING MUSCLE
ENERGY TECHNIQUES
In order to strengthen the same muscle groups,
retract your right thigh and project your left. Twist
trunk to the left and grasp the right leg with the
left hand. Now extend and rotate the trunk to the
left while projecting the right thigh and retracting
the left. Provide resistance to the trunk rotation
with the left hand. Repeat on other side.

Figure 33.

33
MUSCLE ENERGY EXERCISE FOR THE CORE
ON THE SYMMETRICAL PELVIS
Strengthening the rectus abdominis and the
abdominal oblique musculature is necessary to
help maintain posterior pelvic rotation throughout
the day. This exercise is done on the symmetrical
pelvis. Place both hands on the same knee,
tighten your abs and pinch your buttocks tightly
together. Push down hard on that knee for
several seconds. Repeat on the other side. Do
five times on each side.

Repeat throughout the day.

Figure 34

ACTIVE EXERCISE FOR THE CORE, GLUTES AND THIGHS

Seated, simply tighten your abs and glutes, hold tight, lean forward and rise to standing, slowly. Then, still
holding your abs and glutes tightly, sit slowly. Repeat ten times.

Always tighten your abdominal muscles when standing and sitting, especially the rectus abdominis

.PAIN ON SITTING

Figure 35. A folded pad three to four inches thick placed under the upper thigh back to, but not
underneath the ischial tuberosity, will create a posterior innominate correction force to relieve
pain in the low back when sitting.

34
 Medical Management

Sequence (Non-invasive)
Correct the joint, instruct patient in self-correction and tell him to do the corrective
exercises every two to three hours all day long for the next three days at least in order
to keep the tension off of the affected ligaments and allow them to recover.

On the second day have the patient demonstrate the corrective exercises to you. They
will usually be making errors in technique that will preclude a good result and must be
re-instructed. If the patient is doing the exercises properly he/she should be told to only
return if the pain continues over 10 days.

If the pain still recurs after ten days the patient should be put into a lumbosacral
support. This support is to be put on when lying down on it and after making a
correction. If progress continues with the support the patient can wean himself as
indicated.

If the dysfunction is still unstable after one month, proliferant injections are indicated into
the long and short posterior sacroiliac ligaments. These are the only ligaments so
affected.

Contraindications
Contraindications are few.

• Do not stretch a tight psoas. Correction will restore normal tension in the psoas.

• No double or single straight leg raising.

• No sit-ups with the legs out straight.

• Never correct into pain. If what you are doing causes pain use a different correction.
Hip fractures or hip replacements are not contra indications. Just change to a direct
correction by grasping the pelvis directly without using the leg as a lever.

• Never prolo the iliolumbar ligaments until the SIJ is corrected and stable. This may
preclude the possibility of achieving correction.

35
• Never correct for a posterior dysfunction or an upslip. This correction is unsafe and
potentially harmful.

Invasive Methods
Invasive procedures may be necessary if conservative measures fail. Begin with the
least invasive measures first:

Local Anesthetic
Periarticular injections of local anesthetic and steroid to the area of the posterior
inferior Iliac spine and the posterior superior iliac spine to relieve acute pain and
inflammation.

Proliferant injections
Proliferant injections to the long and short posterior sacroiliac ligament to stabilize the
joint. Do not proliferate any other ligaments until the joint is stable or you might tighten
the joint in the uncorrected position and preclude the possibility of correction. Always
proliferate with the SIJ in the corrected position of posterior innominate rotation.

There may be some value in proliferating the long and short posterior sacroiliac
ligaments in the early stages of low back pain. This might strengthen those
ligaments to limit collagen failure, help to prevent recurrence of dysfunction and
preserve the system. If ligamentous balance is not maintained the collagen may still fail
in the long posterior sacroiliac ligament even if it has been proliferated.

Stability of the lower lumbar vertebra is restored with correction and stabilization of the
sacroiliac joint. If after the sacroiliac joints are stabilized in the balanced position the
iliolumbar ligaments may be proliferated if they are still unstable.

The Failed Back

In the patient with multiple fusions and a failed back, in the likely event of an unstable
SIJ, it is probably critical to preserve function with ligamentous repair rather than
stabilize. The importance of these joint to absorb, modify and redirect the various forces
that occur during normal gait can not be overstated. Excess rigidity will predispose to
systems failures.

Failed prolo
Prolo may not be effective if:
1. The superficial long posterior sacroiliac ligament has undergone extreme visco

36
elastic failure.
2 The ligaments are shredded or otherwise traumatized.
3. The ligaments are not in a corrected and shortened position when injected.
4. If the ligaments are avulsed from attachment to the PSIS.
5. If the patient has a protruding abdomen and refuses to lose weight.

Ligamentous Repair
If it is not possible to stabilize the joint with proliferant then you might consider
ligamentous repair of the long posterior SI ligament. It is superficial and quite
accessible. It may be feasible to transfer tendon from the adjacent sacrospinalis muscle
to the PSIS and marry it with proliferant to the long posterior SI ligament. Always
operate with the joint in the corrected position.

Surgical Fixation
In the event of severe joint injury and gross ligamentous instability surgical fixation may
be necessary. Fixate in the corrected position. Caution the patient as to limiting
activities that create or increase the asymmetric pelvis. If these activities are blocked
posteriorly they will manifest anteriorly and destabilize the symphysis.

After fixation, if the patient uses a non-weight bearing gait, the ipsilateral leg hanging
down from the innominate bone will cause a force in anterior rotation on the pelvis and
might cause a non-union to occur.

The Epidural
An epidural anesthetic may relieve the pain of SIJD because of the lumbar innervation
of the SIJs, however this should not be interpreted as relief of a referred pain of lumbar
origin. It is more effective to treat locally to relieve pain and inflammation.

The Piriformis Release

If correcting the SIJ does not relieve the pain or if the patient has an SIJ fixation in the
uncorrected position, consider releasing only the secondary origin of the piriformis from
the roof of the greater sciatic notch to preserve function in that muscle. Cutting the
tendon of the piriformis muscle decreases sacral stability during ambulation.

__________
Note to Physicians

When ordering therapy please specify the DonTigny Method. Many therapists are still
using methods based on standard AAOS testing or are using traditional side-lying
manipulations

37
Patients cured immediately with self-treatment

Hello,

I'm not sure if you are still checking these e-mails but I wanted to take a moment and write you on how
your very simple sacroiliac movement has ended several years of chronic and severe lower back pain. I
fell off a barstool about three years ago and ever since then have had severe pain in my right SI joint that
sometimes would radiate down my leg. NSAIDs were the only way for me to get temporary relief. I did
approximately 60 spinal decompression treatments because the MRI showed a disc bulge at L5/S1 ( the
bulge was on the left!). If anything the spinal decompression treatments made me more sore. To say I
was desperate would be an understatement. I was under the assumption that my condition was caused
by internal disc disease and that the pain was due to the release of chemicals into the surrounding tissue
as the disc degenerated. As a chiropractor who also owns a multidisciplinary clinic I tried everything.
Friday I was reviewing your website and tried the simple motion several times on each leg while lying on
my bed. It seemed the pain decreased. I was sure this was only in my head. Being desperate I continued
the exercises several times that day. Saturday I woke up, again with no pain. I put up all my Christmas
lights climbing on a ladder all day long, stopping occasionally to do the movement. This is Monday still no
pain. I am shocked and in disbelief!

Immediately, today I began teaching your movement to all our patients and to all the doctors that work for
me. Could it be that simple? I wonder how many people I have personally misdiagnosed with
herniated/bulging discs that really had sacroiliac problems? Since your procedure is noninvasive and
puts no torque of a lumbar disc I am implementing it as part of my general protocol for all our lumbar disc
patients, as I see it there should be no contraindications in the patient doing this.

Do you have any comments on correlation between the sacroiliac problem and lumbar disc disease? In
the past I've done quite a bit of HVLA and honestly believe it can aggravate herniated disc, but your
maneuver, I believe, is very safe. I'm not too sure about diagnosing the condition, but honestly what
harm does it do to just get the patients doing the movement.

Again thank you. I'm still in disbelief but I'm very happy to be free of my chronic pain.

Dr…SS….DC.

Dear Richard Dontigny, P.T.,

Three hours ago, I tried the direct correction with the Impulse adjusting instrument. I alternated both sides
4 times each. It took that many times until the legs didn't shorten anymore. I am now completely out of
pain. This is amazing. I have been in almost constant pain since 1999. Now after doing your correction,
all my pains are completely gone. It took 30 minutes for the pain to completely disappear.

Here is a description of my usual pain: left hamstring tightness, right iliolumbar ligament pain, left
sacrotuberous pain, base of skull pain, shoulder blade pain, left foot pronation, epididymitis pain, left
round ligament pain, left groin pain, left calf pain, headache pain, a shorter than normal walking stride,
and right long dorsal ligament pain. I have had these pains since 1999, with most of them being constant
all day long. I even have left eye twitches when I am really out of alignment.

Since the correction three hours ago, I have no discomfort anywhere.

38
I have palpated my sacral base, since the correction. I noticed it went into sacral nutation. From reading
about SIJD, this seems to be the more stable position. Is this correct? Can the sacral base go too far into
nutation when the innominates go into posterior rotation during correction? You mentioned the ilia ridge
that prevents over correction of the posterior innominate rotation. Does this ridge also protect the sacral
base from over correction?

Thank you very much for taking the time to write to me. I bet the health care costs of our nation would be
much cheaper, if the medical profession would adopt methods like yours, that are safe, reliable, effective,
and simple to perform.

How many chiropractors would need to attend, if I had one of your instructors come to my area to teach a
seminar?

There are around 200 chiropractic technique systems. They all teach to adjust the innominates into
anterior rotation. I figure all P.T. and osteopathic technique systems teach the same absurd thinking. I
also had the same absurd thinking for years too, and that was making my pain worse. Your information
along with the information from Joseph Shaw, M.D. are the only ones that I have seen that teach to
correct into posterior rotation.

Thanks again for answering my questions.

Sincerely,

T.J,, D.C.

Dear Mr. Tigny,

I am a physician with a long history of SIJD, with the recent addition of arthroscopic labral
repair/acetabuloplasty and foot fusion for TMT instability (Morton’s foot).

I have gotten benefit from chiropractic maneuvers in the past but always felt them to be a little rough. My
best experience with traction type interventions was the day after my right hip surgery. The PT
goddess working with the Orthopedic surgeon unlocked my right SIJ (the usual culprit and so bad the
day after surgery that I could not lift my pelvis off the PT table while supine) using gentle traction
maneuvers.

I have looked around the web before and somehow found your site today. Your site is the biggest, most
comprehensive repository of physiologically accurate, biomechanically sensible "non-
violent" interventions I have yet seen.

I look forward to using a number of your maneuvers and receiving the CD. Hopefully this will help begin
to address the gluteus medius/ PSIS tenderness I have and much of the issues with trigger points that
have gotten worse after years of reading x rays.

I will definitely send you some more comments after I have had a chance to use a few more
maneuvers. Feel free to use any of my words. I think your site is excellent. Thank you for having it
available.

Warm regards,

Ingrid K. Schneider, MD

39
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32. Yeoman W. The relation of arthritis of the sacroiliac joint to sciatica. Lancet .1928; 2:1119-1122
33. Davis P, Lentle BC. Evidence for sacroiliac disease as a common cause of low backache in women.
Lancet . 1978; 2:496-497

34. Tingren J, Soinila S. Reversible pelvic asymmetry. J Manipulative Physiol Ther. 2006; 29(7):561-5

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34A. Timgren J: Re-Establishing Pelvic Symmetry In Patients Suffering From Diverse Forms Of
Musculoskeletal Pain - A retrospective study of 553 patients with a reversible pelvic obliquity. Rejected by
Editor; Journal of Manipulative and Physiological Therapeutics 2/feb/2013

35. DonTigny RL. Measuring PSIS movement. Clinical Management. 1990; 10:43-44

36. White AA: Introduction. In White AA, Gordon SL (eds) :American Academy of Orthopaedic Surgeons
Symposium on idiopathic low Back Pain. St. Louis, MO, CV Mosby Co, 1982, p 2

FYI List of a few references on the pelvis and sacroiliac joint

McConnell CP, Teall CC: the Practice of Osteopathy. Third Edition. Kirksvillle, Mo., The Journal Printing Co. 1906

Cunningham DJ, cited by Dwight T, et al: Human Anatomy. Including Structure and Development and Practical
Considerations. Edited by GA Piersol. Philadelphia, JB Llippincott Co.,1907, p 346

Platt R: Pelvic technique. J Am Osteopath Assoc 1486-88, 1914.

Baer WS: Sacro-iliac strain. Bull. Johns Hopkins Hosp. 28: 159, 1917

Smith-Petersen M, Rogers W: End-result study of arthrodesis of the sacroiliac joint for arthritis, traumatic and non-
taumatic. Journal of Bone and Joint Surgery 8:118-136, 1926

Sciatica was thought to be caused by dysfunction in the sacroiliac joint in the early 1900s. In 1928 Yeoman reported
that sacroiliac arthritis was responsible for 36% of the cases of sciatica.
Yeoman W: The relation of arthritis of the sacroiliac joint to sciatica. Lancet 1928: 2:1119-1122

Chamberlain, WE: The Symphysis Pubis in the Roentgen Examination of the Sacroiliac Joint. Am J Roentgenol
Radium Ther Nucl Med 24:621-625, 1930

Frieberg AH, Vinke TH: Sciatica and the sacroiliac joint. J Bone & Joint Surg. 16:126, 1934

Bailey HW, Beckwith CG: Short leg and Spinal anomalies. Their incidence and effects on spinal mechanics. JAOA
36:319-327, 1937

Smith-Petersen MN: Arthrodesis of the Sacroiliac Joint. A New Method of Approach. J Orthop Sur 3:400-405, 1938

Rauber-Kopsch found that a part of the sciatic nerve passed through the piriformis muscle and joined the other
portion of the nerve to form a main trunk at the caudal margin of the muscle. Rauber-Kopsch F: Lehrbuch and Atlas
der Anatomie des Menschen. Edited by Kopsch F, Thierme G, Leipzig 1940-43

Anderson Rl, Peterson Vl. Clinical use of the Chamberlain technic in sacroiliac conditions. J Am Med Assoc
1944;124:269–71.

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Platt H: Backache - Sciatica syndrome and intervertebral disk. Rheumatism 4:218, 1948

Shuman D: Technic for treating instability of the joints by sclerotherapy. Osteopathic Profession, May 1953

Weisl H: The relation of Movement To Structure in the Sacroiliac Joint. PhD Thesis, Manchester, England,
University of Manchester, 1953

Weisl H. Movement of the sacroiliac joint . Acta Anat (Basal)23;80-91, 1955

Kallio KE: The problem of back pain and sciatica: a report of recent experiences. Duodecim 1-2:1, 1955

Norman GF, May A: Sacroiliac Conditions Simulating Intervertebral disc Syndrome. West J Surg Obstet Gynecol
461-462, 1956

Hackett GS, Huang TC: Prolotherapy for sciatica from weak pelvic ligaments and bone dystrophies. Clinical Medicine
8(12):2302-2316, 1961

Norman GF: Sacroiliac disease and its relationship to lower abdominal pain. Am J Surg 116:54-56, 1968

Grant JCB: A Method of Anatomy. Descriptive and Deductive. Sixth Edition. Baltimore, Williams & Wilkins Co., 1968

Coventry MB, Tapper EM. Pelvic instability: a consequence of removing iliac bone for grafting. J Bone Joint Surg
Am. 1972 Jan;54(1):83–101

DonTigny, RL: Evaluation, manipulation and management of anterior dysfunction of the sacroiliac joint. The D.O. 14:215-226, 1973

Hiltz DL: The sacroiliac joint as a source of sciatica: A case report. Phys Ther 56:1373, 1976.

DonTigny, RL: Letter to Editor: Sciatica and the Sacroiliac Joint. PT March 1977, p 143

Davis P, Lentle PC: Evidence for sacroiliac disease as a common cause of low backache in women. Lancet 2:496-97,
1978

LaBan MM, Meerschaert JR, Taylor RS, Tabor HD. Symphyseal and sacroiliac joint pain associated with pubic symphysis instability.
Arch Phys Med Rehabil 1978;59:470–2.

DonTigny, RL: Dysfunction of the sacroiliac joint and its treatment. JOSPT 1:13-25, 1979

Grieve GP: Common Vertebral Joint Problems, New York, NY, Churchill Livingstone Inc, 1981

Farfan HF, Kirkaldy-Willis WH. The present status of spinal fusion in the treatment of lumbar intervertebral joint
disorders. Clin Orthop Relat Res. 1981 Jul-Aug;(158):198–214

Gajdosik R, Simpson R, Smith R, DonTigny RL: Pelvic Tilt: Intratester reliability of measuring the standing position
and range of motion. Phys Ther 65:168-174, 1985

DonTigny, RL: Function and pathomechanics of the sacroiliac joint. Phys Ther 65:35-44, 1985

DonTigny, RL: Function, Dysfunction and Manual Treatment of the Sacroiliac Joint. In Nwuga VC (ed): Manual Treatment of Back
Pain. Malabar, Florida, Robert E. Krieger Publishing Co., 1985, Chpt 8, pp 122-152

Ongley ML, Klein RG, Dorman TA et al: A new approach to chronic back pain. Lancet 2:143-6, 1987

Sturesson B, Selvik G, Uden A: Movements of the sacroiliac joints. A roentgen stereophotogrametric analysis. Spine
14:162-165, 1989

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DonTigny, RL: Sacroiliac Dysfunction, Recognition and Treatment. Postgraduate Advances in Physical Therapy. Course III, Berryville,
VA, Forum Medicum, Inc. 1990, pp 1-33

DonTigny RL: Anterior dysfunction of the sacroiliac joint as a major factor in

the etiology of idiopathic low back pain syndrome. Physical Therapy 70:250-265, 1990

DonTigny, RL: Measuring PSIS movement. Clinical Management 10:43-44, 1990

Vleeming A. The Sacroiliac Joint: A Clinical Anatomical Biomechanical and Radiological Study. 1990. Thesis Erasmus University
Rotterdam. Rotterdam.

Vukicevic S, Madrusic A, Stavljenic A, Vujicic C, SkavicJ, Mukicevic D, Holigraphic analysis of the human pelvis.
Spine 16:209-214, 1991

Alderink, , GJ: The Sacroiliac Joint: Review of Anatomy, Mechanics, and Function Journal of Orthopaedic & Sports
Physical Therapy, 1991, Volume: 13 Issue: 2 Pages: 71-84 doi:10.2519/jospt.1991.13.2.71

DonTigny, RL: Sacroiliac joint as a major source of low back pain. Back Pain Monitor, April 1991, pp 55-58

DonTigny, RL: Sacroiliac joint dysfunction responds well to manual therapy. Back Pain Monitor, May 1991

Shaw, JT: The role of the sacroiliac joint as a cause of low back pain and dysfunction. In: Vleeming A, Mooney V,
Snijders CH, Dorman T(eds): First Interdisciplinary World Congress on Low Back Pain and its Relation to the
Sacroiliac Joint. San Diego, CA November 5-6, 1992, pp 67-80

Shaw, orthopedic surgeon at the Topeka Back and Neck Center, did a study of 1,000 consecutive patients with low
back pain and found that 98% had this dysfunction. His surgical rate for herniated discs dropped to 0.2%.

Paris VP. Differential diagnosis of sacroiliac joints from lumbar spine dysfunction. In: Vleeming A, Mooney V, Snidjers
CJ, Dorman T, editors. Proceedings of the First Interdisciplinary World Congress on Low Back Pain and its Relation
to the Sacroiliac Joint. Rotterdam: European Conference Organizer; 1992. p 1-64.

DonTigny, RL: Mechanics and treatment of the sacroiliac joint. Journal of Manual & Manipulative Therapy, 1:3-12, 1993

Snijders CJ, Vleeming A, Stoeckart R. Transfer of lumbosacral load to iliac bones and legs Part 1: Biomechanics of self-bracing of the
sacroiliac joints and its significance for treatment and exercise. Clin Biomech (Bristol, Avon) 1993;8:285–94

DonTigny, RL: Function of the lumbosacroiliac complex as a self-compensating force couple with a variable, force-dependent
transverse axis: A theoretical analysis.
JMMT, 2:87-93, 1994

DonTigny, RL: The DonTigny low back pain management program. JMMT, 2:163-168, 1994

Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995;20:31-7.

Smidt GS, McQuade K, Wei SH, Barakatt E: Sacroiliac kinematics for reciprocal stride positions. Spine 20(9):1047-1054, 1995

DonTigny, RL: Functional Biomechanics and Management of the Pathomechanics of the Sacroiliac Joint. In Dorman TA (ed): SPINE:
State of the Art Reviews. Philadelphia, PA, Hanley & Belfus, Inc. 1995, Chpt 14

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Moore M: Diagnosis and surgical treatment of chronic painful sacroiliac dysfunction. Vleeming A, Mooney V Dorman T, Snijders R
(eds): Second Interdisciplinary World Congress on Low Back Pain. san Diego, CA, Nov 9-11, pp339-354 1995

Dorman TA, Brierly S, Fray J, Pappani K: Muscles and pelvic clutch: hip adductor inhibition in anterior rotation of the
ilium. Journal of Manual and Manipulative Therapy 1995, 3:85-90

Vleeming A, Pool-Goudzwaard AL, Hammudoghlu D, Stoeckart R, Snijders CJ, Mens JMA. The function of the long
dorsal sacroiliac ligament: its implication for understanding low back pain. Spine (Phila Pa 1976) 1996;21:556–62.

Maigne JY, Aivaliklis a, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests
in 54 patients with low back pain. Spine 1996;21:1889–92

Dannanberg H J: Lower back pain as a gait-related repetitive motion injury. In Vleeming A, Mooney V, Dorman T,
Snijders C, Stoeckart R (eds): Movement, Stability & Low Back Pain: The Essential Role of the Pelvis, London,
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Keating JG, Avillar MD, Price M: Sacroiliac joint arthrodesis in selected patients with low back pain. In: Vleeming A,
Mooney V Dorman T, Snijders R (eds): Movement, Stability & Low Back Pain: The Essential Role of the Pelvis.
London, Churchill Livingstone, pp 573-586, 1997

Fortin JD, Falco FJE. The Fortin finger test: an indicator of sacroiliac pain. Am J Orthop MEAD- 1997;26:477–80.

Lippitt AB: Percutaneous fixation of the sacaroiliac joint. In: Vleeming A, Mooney V Dorman T, Snijders R (eds):
Movement, Stability & Low Back Pain: The Essential Role of the Pelvis. London, Churchill Livingstone, pp 587-594,
1997
Mens JMA, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ. The active straight leg raising test and mobility of the pelvic
joints. Eur Spine J 1999;8:468–73.

Fortin JD, Washington WJ, Falco FJE. Three pathways between the sacroiliac joint and neural structures. Am J
Neuroradiol 1999;20:1429–34.

DonTigny, RL: Critical analysis of the sequence and extent of the result of the pathological release of self- bracing of
the sacroiliac joint. Concurrently in JMMT 7:173-181, 1999 and J of Ortho Med (UK) 22:16-23,2000

Slipman CW, Lipetz JS, Plastaras CT, et al. Fluoroscopically guided therapeutic sacroiliac joint injections for
sacroiliac joint syndrome. Am J Phys Rehabil 2001;80:425-32.

Damen L, Buyruk HM, Güler-Uysal F, Lotgering FK, Snijders CJ, Stam HJ. with asymmetric laxity of the sacroiliac
jointsPelvic pain during pregnancy is associated. Acta Obstet Gynecol Scand 2001;80:1019–24.

Damen L, Spoor CW, Snijders CJ, Stam HJ. Does a pelvic belt influence sacroiliac joint laxity? Clin Biomech
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Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of
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Dreyfuss P, Dreyer SJ, Cole A, Mayo K. Sacroiliac joint pain. J Am Acad Orthop Surg 2004;12:255-65.

Al-Eisa E, Egan D, Wassersug R. Fluctuating asymmetry and low back pain. Evol Hum Behav 2004;25:31–7.

Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation
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DonTigny, RL: Critical analysis of the functional dynamics of the sacroiliac joints as they pertain to normal gait. J of
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Cohen, SP: Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis and Treatment. Anesth Analg
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Spine 23(2):1-8 · May 2015
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radiofrequency denervation for sacroiliac joint pain. Dec 2015 · Egyptian Journal of Anaesthesia

DonTigny RL: Evidence of Errors That Have Stymied Low Back Pain Research: A plea for more appropriate care.
Unpublished 2016

DonTigny RL: The Four Types of Pelvic Movement: Dysfunction as a Pseudo-Multifactorial Lesion
Unpublished. 2016

DonTigny RL: The Science of Pelvic Dynamics and the Subluxation of the Sacral Axis. Download. Bozeman,
Montana, (c) registered 2001 and continuously revised through 2016 ($495.00 through www.thelowback.com)

DonTigny, RL: The Sacral X Axes:

Location, Structure, Movement, Parallel Kinetic Ligamentous Loading, Function, Biotensegrity Technology and
Pathology. The Essential Pieces of the Low Back Pain Puzzle. (June 18, 2017). ). Available at
SSRN: https://ssrn.com/abstract=2988680. This is a free site.

http://www.greatseminarsonline.com Corrections on actual patents with immediate relief of pain. Five CEUs

www.kalindra.com/sacroiliac2.htm
www.thelowback.com

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