Validacion Del Long Sitting Test

01 96-601 1 /87/0807-0336$02.00/0 THE JOURNAL OF ORTHOPAED~C AND SPORTS PHYSICAL THERAPY Copyr~ght O 1987 by The Orthopaedic and Sports Physical Therapy Sections of the American Physlcal Therapy Association

Validation of the Long Sitting Test on Subjects with lliosacral Dysfunction* TERRY BEMIS, CPT, BS, OTR, MPT,t MONTE DANIEL, lLT, BA, MS, MPTt

This study investigated the use of the long sitting test as an indicator of iliosacral dysfunction. Fifty-one subjects between the ages of 18 and 37 were assigned to either an experimental group or control group through a screening procedure. The 30 subjects in the control group had even posterior superior iliac spine (PSIS) heights and negative standing and sitting flexion tests. The 2 1 subjects in the experimental group had uneven PSIS heights, positive standing flexion tests, and negative sitting flexion tests. Measurements were taken of the change in the subjects' malleoli as they moved from a supine to a sitting position. Additional suppkmental and confirmational tests were then administered. The results of the long sitting test for iliosacral dysfunction were found to be significant at the 0.01 level. Possible influences on this test indicated by the confirmational and supplemental tests were also explored.

The selection of an effective manual physical therapy procedure depends upon the correct diagnosis of the dysfunction. Multiple clinical tests assist the physical therapist in formulating a par- ticular diagnosis. A clinical test frequently performed by orthopaedic physical therapists in the evaluation of iliosacral dysfunctions is the long sitting test (LST).

Numerous studies have documented the presence of motion at the sacroiliac joint^.^^^^^^^^'^^'^ The movements, which are minimal and involun- tary, may include the sacrum moving between the innominates or the innominates moving on the sacrum. Although the sacral movements can be complex, as they can occur around five axes of motion, the prirlciple movement of the innominates is r~ ta t ion .~ The manner in which the sacrum and innominates move on each other forms the basis upon which sacroiliac or iliosacral dysfunction is diagnosed.

Sacroiliac dysfunction suggests an abnormal motion of the sacrum within the ilia, and specific clinical findings include forward and backward sacral torsions and unilateral f le~ion. '~. '~ Mitchellg

' The opinions or assertions contained herein are the private views of the authors and are not to be construed as official Or as reflecting the vlews of the Department of the Army or the Department of Defense. t U.S. Army/Baylor University, Master of Physical Therapy Program, Academy of Health Sciences, Fort Sam Houston. San Antonio, TX 78240.

states that muscles, fascia, ligaments and other structures of the spinal mechanism produce and maintain these dysfunctions. A positive sitting flexion test indicates that a sacroiliac dysfunction is present.

lliosacral dysfunctions consist of abnormal mo- tions of the ilia moving on the sacrum, and are often produced and maintained by tissues of the lower extremities and abd~men.~ Minimal diagnostic criteria for establishing the presence of an iliosacral dysfunction includes the presence of uneven posterior superior iliac spine (PSIS) heights, a positive standing flexion test, and a negative sitting flexion test.l5 The diagnostic se- quence follows this order: the presence of uneven PSIS would suggest that a lesion is present; the standing flexion test would reveal which side the lesion is on; and the sitting flexion test would rule out sacroiliac dysfunction. The most common iliosacral dysfunctions are classified as either anterior or posterior inn om in ate^.^^^^'^-^^ An anteriar innominate indicates that the innominate is fixed in a position of forward rotation (high PSIS), and a posterior innominate suggests a fixed backward rotation of the innominate (low PSIS).

The long sitting test is also commonly used as an indicator of iliosacral dysf~nct ion. ' .~* '~. '~ T o perform the test, the subject lies supine on a plinth while the therapist compares the relative

JOSPT January 1987 LONG SITTING TEST

positions of the medial malleoli. The subject then pulls himself to the long sitting position, being careful not to deviate from the midline. The therapist again compares the positions of the malleoli to each other. The overall movement of the medial malleolus on the side of the positive standing flexion test is then determined. If an anterior innominate is present, an apparent leg shortening occurs as the malleolus moves from a longer to a shorter position in comparison to the contralateral medial malleolus. A posterior innominate would produce an apparent leg lengthening as the malleolus moves from a shorter to a longer position.

The mechanism for the apparent changes in leg length depends on the position of the acetabulum on the side of the iliosacral dysfun~tion.~," In a supine subject with a posterior innominate, the acetabulum is positioned anterior-superior to the "normal" position resulting in a shortened leg. As the subject assumes a sitting position, the acetabulum moves around an arc of motion ending in a position which is inferior to the normal and results in an apparent long leg. The opposite is true for an anterior innominate (Fig. 1).

In addition to the clinical findings cited above, other physical signs of an iliosacral dysfunction have been r e p ~ r t e d . ' ~ ~ ~ ~ . ~ ~ ' ~ . ' ~ In an anterior innominate the anterior-superior iliac spine (ASIS) is low in comparison to the contralateral ASIS; the medial sacral sulcus, formed by the ilium overlap- ping the sacrum, is shallow; and the iliac crest is lower on the same side as the dysfunction. In a posterior innominate, the ASlS is high, the medial sacral sulcus deeper, and the iliac crest higher.

ln the supone position : Posterior rotation 01 the ilium on the sacrum

would shorten the leg on that

. .

/ / I n the lona sitting ooaition the reverse occurs:

Fig. 1 . The long sitting test to determine iliosacral dysfunction

METHOD

Subjects

The subjects were 28 men and 23 women, ranging in age from 18-37 years (X = 26.9). They were selected from a larger sample of active duty military personnel assigned to the Academy of Health Sciences, Fort Sam Houston, TX. Based upon screening results, volunteers were divided into a control group consisting of 30 normals and an experimental group of 21 iliosacral dysfunctions.

Screening Procedure

While standing, the volunteer's bare feet were neutrally positioned 15 cm apart on a gridded base to ensure standardization of lower extremity alignment, and to prevent leg lengthening or shortening influences from either internal or external rotation of the hips. The researchers then palpated and documented the heights of the iliac crests, PSIS, and ASlS as either high or low.

While the subject remained in the standardized position, the standing flexion test was performed. After palpating the inferior aspect of each PSlS (Fig. 2), the researcher observed the excursion of his fingers on the PSlS as the subject bent for-

(from Saunderslz). Fig. 2. The standing flexion test, erect position.

338 BEMlS AND DANIEL JOSPT Vol. 8, No. 7

ward to the limit of trunk flexion (Fig. 3). If one PSlS moved more superiorly than the other, the test was considered to be positive for that ~ i d e . ~ , ' ~

Next, the sitting flexion test was performed. The subject was seated on a low stool to "seat the pelvis." The researcher again palpated the PSlS (Fia. 41 and observed the excursion of his , " r

fingers as the subject bent forward (Fig. 5). If one PSlS moved more superiorly than the other, the test was considered positive for that ~ i d e . ~ . ' ~

Those subjects with equal PSlS heights and negative standing and sitting flexion test results were placed in the control group. Subjects who met the minimal criteria for iliosacral dysfunction (unequal PSlS heights, a positive standing flexion test and a negative sitting flexion test) were placed in the experimental group. Those subjects displaying other combinations of these clinical findings were excluded from the study (Fig. 6).

Experimental Procedure

The second phase of the study was conducted immediately following classification of the subjects as either control or experimental. The subject was positioned supine on a plinth which had a lami- nated 16 x 20 inch sheet of plywood clamped to its foot. A sheet of standard 8 x 11 inch metric- scaled graph paper was mounted on the center

Fig. 4. The sitting flexion test, erect position.

Fig. 5. The sitting flexion test, flexed position.

of the board. After positioning the subject with his ankles over the paper grid, the most inferior bor- der of each medial malleolus was marked as a reference point.

To ensure a neutral alignment of the pelvis on the plinth, the subject performed a bridging technique which consisted of flexing his knees to place

Fig. 3. The standing flexion test, flexed pos~t~on. his feet flat on the plinth, extending his hips to lift

JOSPT January 1987 LONG SITTING TEST 339

Screening

1. Palpation of PSIS, ASIS, and iliac crests 2. Standing flexion test 3. Sitting flexion test

Experimental Group Inconsistent Findings Control Group

1. Unequal PSIS (Not included in study) 1. Equal PSIS 2. Positive standing 2. Negative standing

flexion test flexion test 3. Negative sitting 3. Negative sitting

flexion test flexion test

Experimental Procedure

1. Long sitting test

Confirmational and Supplemental Testing

Fig. 6. Flow chart.

the buttocks from the surface, and then relaxing to allow the buttocks to return to the plinth (Fig. 7). One researcher, stationed at the foot of the plinth, then grasped the subject's ankles and extended the legs so that the feet were positioned neutrally overtthe paper grid (Fig. 8).

A marker, constructed of a 9 x 1 inch plexiglass strip with a reference line scribed down the center and bent to a 90° angle, was then positioned so that the vertical reference line was in line with the mark on the subject's medial malleolus, and the horizontal reference line was parallel to the lines on the grid (Fig. 9). The position was then re- ~orded on the grid, and the procedure was re- Fig. 7. Bridging technique for neutral alignment of the subject's peated on the other medial malleolus.' pelvis OH the plinth.

The subject was then asked to pull himself up to a sitting position without deviating from the midline while his feet were maintained in the neutral position (Fig. 10). The positions of the medial malleoli were again recorded on the grid by a researcher using the plexiglass marker.

Supplemental Data Collection

Following completion of the long sitting test, a series of confirmational and supplemental tests were administered for analysis of possible influences on the experiment. These tests included palpation of the sacral sulci (Fig. 1 I), sacroiliac fixation test (Fig. 12), hip range of motion, gross muscle testing, leg length measurements, the Thomas test, the Ober test, hamstring flexibility, SI compression/distraction tests, the FABERE Fig. 8. Researcher extends and positions the subject's legs.


jects previously classified as normals and whose LST results dib not reveal a short to long or a long to short switch in position. Group 2 consisted of those normals whose LST results produced a switch from short to long, or long to short. Group 3 included the subjects with iliosacral dysfunction and whose LST results agreed with their specific diagnosis of an anterior or posterior innominate. Group 4 consisted of the subjects with iliosacral dysfunction, but whose LST results did not cor- respond with their diagnosis. The final tabulation

Fig. 11. Palpation of depth of sacral sulci

Fig. 10. Subject pulls himself up to long sitting position.

test, and the prone knee flexion test (Figs. 13, 14). (See Appendix I for further test descriptions.) Any postural or gait deviations were noted in the comments section of the data collection sheet (Appendix 11).

Following data collection, the directions and net movements of the malleoli were tabulated. Based upon these results, subjects were placed into one of four groups: Group 1 consisted of those sub- Fig. 12. Sacroiliac fixation test.


Fig. 13. Prone knee flexion test, knees extended.

Fig. 14. Prone knee flexion test, knees flexed.

placed 25 subjects in group 1, 5 in group 2, 13 in group 3, and 8 in group 4. A chi-square distribution was used to test the null hypothesis that the LST results and the presence or absence of iliosacral dysfunction are independent. A .2 x 2 contingency table, shown as Table 1, was established to show the frequency of each occurrence.

The total malleolar movement in millimeters, leg length differences in centimeters, and hamstring length difference (HLD) in degrees were also recorded. Table 2 shows the mean, standard devia- tion, and variance of each variable for each group. A two-tailed t-test was performed to test for differences between variable means.

Supplemental data was analyzed for frequence of occurrence and for possible effects on the experimental tests. Specific frequencies of occurrence for high iliac crest (HIC), high ASlS (HASIS), deep sacral sulcus (DSS), short hamstring (SHS), and long leg (LL) each on the side of the iliosacral dysfunction were tested for significant differences using a chi-square distribution.

TABLE 1 Chi-square distribution-observed frequencies

Diagnosis LST results

Normal lliosacral dysfunction

Switch 5 13 No switch 25 8

Chi-square = 11.07; d.f. = 1 ; a = 0.01.

RESULTS

The expected contingency table of no difference between normal and iliosacral dysfunction LST results is presented in Table 3. Since the critical value of chi-square at CY = 0.01 with 1 degree of freedom (6.64) is less than the tabulated value of chi-square (1 1.07), the test concludes that a difference does exist between groups. A comparison of observed versus expected frequencies of occurrence reveals a higher frequency of normals (group 1) and iliosacral dysfunctions (group 3) producing anticipated LST results than those that did not (groups 2 and 4).

Except for the means of the net malleoli movements during the LST between the normals in group 1 and the normals in group 2, there were no statistically significant differences between means on LST movements, leg length differences, and hamstring lengths for any of the groups in this sample. T-test results of mean differences are presented in Table 4.

All subjects in this sample were noted as having symmetrical AROM, muscle strength, Thomas test, Ober test, and sacroiliac fixation test results. Only two subjects, each in group 1, demonstrated sacroiliac joint pain secondary to the SI compression/distraction and FABERE tests. Observations concerning the presence of a HIC, HASIS, LL, SHS, and DSS as they occurred in relationship to the side of the iliosacral dysfunction for those subjects classified as anterior and posterior innominates are listed in Table 5. A chi-square distribution at CY = 0.01 did not reveal statistically significant differences regarding the frequency of occurrence of any variable between groups.

DISCUSSION

The LST was performed on 30 subjects determined to have symmetrical pelvic alignment and on 21 subjects with iliosacral dysfunction in the form of an anterior or posterior innominate. The purpose of this investigation was 1) to determine


TABLE 2 Total malleolar movement (in mm), leg length differences (in cm), and hamstring length differences (in degrees)

Subjects

Group 3 (N = 13) Group 4 (N = 8) Group 1 (N = 25) Group 2 (N = 5) lliosacral dysfunction lliosacral dysfunction

Normals (no switch) Normals (switch) (switch) (no switch)

ic s2 S ic s2 S x s2 S ic s2 S

MM 2.24 6.12 2.47 6.1 6.80 2.61 6.46 22.35 4.73 5.31 26.35 5.13 LLD 0.648 0.20 0.45 0.72 0.24 0.49 0.75 0.34 0.58 1.05 0.29 0.53 HLD 5.76 21.69 4.66 6.00 10.00 3.16 6.00 14.83 3.85 4.00 10.86 3.30

TABLE 3 and deep sulci between anterior and posterior Chi-square distribution of expected frequencies innominate groups did not produce statistical dif-

Diagnosis LST results

ferences. In addition, study results did not appear Normal lliosacral dysfunction to be affected by AROM, muscle strength, hip

Switch 10.59 7.41 flexor length, iliotibial band length, or SI joint pain. NO switch 19.41 13.59 Unfortunately, a comparison of prone knee flexion

Chi-square = 6.635; d.f. = 1 ; CY = 0.01. test results-with the LST could not be made because of testing techniques used.

if the LST is a valid test for confirming the presence of iliosacral dysfunction, and 2 ) to explore other factors which might influence test results.

Study findings revealed that the results of the LST confirmed the diagnosis of iliosacral dysfunction more times than it did not, and that the differences evident between the control and experimental groups were statistically significant. It did not, however, confirm the diagnosis in all cases. Possible reasons may include 1 ) influences from other structures or 2) examiner error.

No statistically significant differences were seen in the mean leg lengths of all groups. In addition, there was no obvious recurrence of a long or short leg on the side of the iliosacral dysfunction. Although a clinically accepted method of measuring leg lengths was utilized, the question of accuracy became rapidly apparent in the cases of innominate rotation. Measuring from either an inferiorly or superiorly positioned ASlS leads to inaccurate leg length measurements.

It has been proposed that a short hamstring muscle may produce a posterior innominate. This study did not show a statistically significant difference between the mean hamstring lengths of groups. Although the LST produced a short to long switch in three normals and in two anterior

The possibility of examiner error in this study exists. Classification of subjects as normal or as having an iliosacral dysfunction is based upon the palpatory skills of the examiner. Thus, the tests used to arrive at a diagnosis are quite subjective. The authors feel that palpation of the medial sacral sulci was the most subjective of the supplemental tests. Obese subjects and subpcts with the presence of nodules in the area of the PSIS made the palpation process more complicated.

Recommendations for further study include: 1 ) employment of a standardized x-ray technique for measuring leg length differences and bony land- marks; 2 ) further assessment of lower extremities to include the presence or absence of genu varus/ valgus or pronated feet as they may affect leg length; 3) examination by experienced orthopaedic physical therapists to compare palpation results; 4 ) inclusion of additional areas of palpation such as lumbar transverse processes for the presence of lumbar malrotation, inferior lateral angles of sacrum to further rule out a sacral lesion, and pubic tubercle heights for pelvic shifts; and 5) comparison of LST results with prone knee flexion test results.

CONCLUSION

innominates, each on the side of the short ham- There are few well established and researched string, the frequency of occurrence of a short tests for iliosacral dysfunction. This study sug- hamstring muscle on the side of the iliosacral gests that the long sitting test is an accurate dysfunction was not statistically notable. method of predicting such lesions. However, the

Comparisons of iliac crest and ASlS heights test should not be used alone, but in conjunction


TABLE 4 Two-tailed t-test results for mean differences

MM LLD HLD

t d.f p t d.f p t d.f p

Group 1 vs group 2 -3.1584 28 0.10 -0.1305 28 0.20 -0.1095 28 0.20 Group 3 vs group 4 0.5239 19 0.20 -1.1677 19 0.20 1.2173 19 0.20 Groups 1 & 2 vs groups 3 & 4 2.9296 49 0.01 1.1604 49 0.20 -0.4785 49 0.20

TABLE 5 Freuuencv of Su~~lemental Observations lliosacral Dvsfunctions

Anterior innominates

Group 3 Group 4

Same side Opposite side Equal Same side Opposite side Equal

High iliac crest 4 2 0 1 0 1 High ASlS 1 4 1 0 1 1 Long leg 2 4 0 0 2 0 Short hamstring 2 4 0 0 2 0 Deep sulci 4 2 0 2 0 . 0

Posterior innominates

Group 3 Group 4

Same side Opposite side Equal Same side Opposite side Equal

High iliac crest 2 4 1 3 3 0 High ASlS 2 5 0 3 3 0 Long leg 0 6 1 1 5 0 Short hamstring 5 1 1 1 4 1 Deep sulci 1 5 1 1 1 4

with other confirmational data for an accurate diagnosis.

The authors would like to thank MAJ Woerman and CPT Stratton for their assistance as advisors for this project; Kathleen Daniel for her many hours of typing; and Emily Bemis for her patience and understand- ing.

REFERENCES

1. Beal MC: The sacroiliac problem: review of anatomy, mechanics. and diagnosis. JAOA 81 (1 0):667-679, 1982

2. Colachis SC, Worden RE. Bechtol CO, Strohm BR: Movement of the sacroiliac joints in the adult male: a preliminary report. Arch Phys Med Rehabil44:490-498,1963

3. Erhard R, Bowling R: The recognition and management of the pelvic component of lowback and sciatic pain. Bull Orthop Section, APTA 2(3):4-15, 1977

4. Frigerio NA, Stowe RR, Howe JW: Movement of the sacroiliac joint. Clin Orthop 100:370-377, 1974

5. Grieve GP: The sacro-iliac joint. Physiotherapy 62(12):384-400, 1976

6. Hoppenfeld S: Physical Examination of the Spine and Extremities. New York: Appleton-Century-Crofts, 1976

7. Kendall FP. McCreary EK: Muscles: Testing and Function. Balti- more: Williams & Wilkins, 1983

8. Kirkaldy-Willis WH: A more precise diagnosis for low-back pain. Spine 4(2):102-109. 1979

9. Mitchell FL Jr: Structural pelvic function. Academy of Applied Osteopathy: 1965 Year Book, Vol 11:178-199

10. Mitchell FL Jr, Moran PS. Pruzzo NA: An Evaluation and Treatment Manual of Osteopathic Muscle Energy Procedures. Valley Park,

Mo.: Mitchell, Moran and Pruzzo Associates, 1979 11. Pitkin HC, Pheasant HC: Sacroarthrogenetic telalgia: II. A study of

sacral mobility. J Bone Joint Surg (Am) 18(2):365-374, 1936 12. Saunders HD: Orthopaedic Physical Therapy: Evaluation and

Treatment of Musculoskeletal Disorders, pp 69-69. Minneapolis: H. Duane Saunders, Publisher, 1982

13. Solonen KA: The sacroiliac joint in the light of anatomical, roent- genological, and clinical studies. Acta Orthop Scand (Suppl) 27:l- 115,1957

14. Stoddard A: Conditions of the sacro-iliac joint and their treatment. ~ h ~ & o t h e r a ~ ~ 44:97-101,1958

15. Sutton SE: Postural imbalance: examination and treatment utilizing flexion tests. JAOA 77:456-465, 1978

16. Weismantel A: Evaluation and treatment of sacroiliac joint prob- lems. Bull Orthop Section, APTA 3(1):5-9, 1978

17. Woerman AL. Binder-MacLeod ST: Leg length discrepancy assessment: accuracy and precision in five clinical methods of evaluation. J Orthop sports Phys Ther 5230-239,1984

APPENDIX 1

Explanation of Confirmational and Supplemental Tests

1. Pelvic Sulci Examination The subject is prone. The examiner palpates the posterior surface of the PSIS with his thumbs. From the posterior surface of the PSIS, the examiner's thumbs are curled medially into the sacral sulci. The sulcus depth is that distance from the peak of


the PSlS to the bottom of the adjacent sulcus. The depths of the sulcus are compared bilaterally, using both observations and palpati~n.'~

2. Prone Knee Flexion Test to 90' The subject lies prone with the cervical spine in the neutral rotation position and arms resting at the sides. The test is best performed with the shoes on. The examiner stands at the foot of the plinth, and grasps the subject's feet with the thumbs passing transversely just anterior to the heel of the shoe and the index fingers just posterior to the lateral malleoli distal fibular shafts. The feet are held in the same degree of pronation/supination and slightly externally rotated. At this point, the relative apparent lengths of the lower extremities are noted. The shorter of the two will be considered to be the side of the lesion. The knees are now flexed to 90' and any change in apparent length is noted. If the short leg appears to increase in length and becomes the longer of the two as the test is performed, this represents a posterior innominate on that side. If the short side stays or becomes even shorter, an anterior innominate is present3

3. Sacroiliac Fixation Test To test the upper part of the joint while the subject is standing, the examiner places one thumb over the second sacral spinous process and the thumb of the other hand over the PSlS of the side to be tested. The subject then flexes both the hip and knee on the side to be tested and lifts the leg as high as possible (at least past 90' hip flexion.) In a normal joint, the thumb placed on the PSlS moves caudally 1-2 cm. In a fixed joint, with reduction of movement, the thumb over the PSlS does not move downward or moves slightly upward. For examination of the lower part of the joint the examiner's thumbs are placed over the apex of the sacrum, the other over the ischial tuberosity on the side to be tested. The subject then flexes the hip and knee as described above. In a normal joint, the ischial tuberosity moves laterally 1-2 cm. In a fixed joint, the tuberosity will remain stationary or move cephalad.8

4. Quick Active Range of Motion Tests6 a. Abduction. Ask subject to stand and to spread his legs apart as far as he can. He should be able to abduct each leg at least 45' from the midline. b. Adduction. lnstruct the subject to bring his legs to- gether from the abducted position, and alternately cross them, first with right leg in front, then with the left. He should be able to achieve at least 20' of adduction. c. Flexion. lnstruct the subject to draw each knee toward his chest as far as he can without bending his back. He should be able to bring his knees almost to his chest (approximately 135' of flexion.) d. Extension. Have the subject sit in a chair. Ask him to fold his arms across his chest, and, keeping his back straight, to get up from the chair. e. Internal Rotation. Have the subject sit on the plinth with knees bent over the side of the plinth. Rotate the thigh of the leg to be tested inward by having the subject swing his foot laterally to 45'. f. External Rotation. Same positon as above. Rotate the thigh of the leg to be tested outward by having the subject swing his foot medially to 45'.

5. Hip Muscle Testing6 a. Flexors. lnstruct the subject to sit upon the edge of the examining table with his legs dangling. The examiner will stabilize the pelvis by placing his hand over the iliac

crest, then ask the subject to raise his thigh from the table. The examiner will place his free hand over the distal end of the thigh and ask the subject to raise his thigh further, while the examiner offers resistance.' b. Extensors. To test the gluteus maximus muscle, the subject will lie prone and flex his knee. The examiner will place his forearm over the iliac crests to stabilize the pelvis, and then ask the subject to raise his thigh from the table. The examiner will use his other hand to offer resistance to the motion leg pushing down on the posterior aspect of the thigh just above the knee joint. The gluteus maximus muscle should be palpated for tone during the test. To test the hamstrings as a group, the patient will lie prone on the plinth. His thigh will be stabilized just above the knee. Then he will flex his knee while the examiner resists his motion at the back of his ankle joint. c. Abductors. With subject supine and his legs abducted about 20°, the examiner will place his hands on the lateral sides of the subject's knees and offer resistance to further abduction. d. Adductors. With subject supine, have him adduct his legs while the examiner exerts resisting pressure on the medial aspects of both knees. e. lntdrnal Rotation. With the subject sitting on the plinth with his legs flexed over the side, the examiner exerts resistance pressure on the lateral surface of the ankle. Stabilize and apply counterpressure to the medial side of the distal aspect of the thigh. f. External Rotation. Same position as above. Resist- ance applied to the medial surface of the ankle. Stabilize and apply counterpressure to the anterolateral surface of the distal femur.6

6. Leg Length Measurement The most accurate, quick clinical measurement of leg length hgs been determined to be from ASlS to lateral malleolus."

7. Thomas Test The subject will be supine on the examining plinth, with his pelvis level and square to his trunk. The subject will flex his hip, bringing his thigh up onto his trunk. The hip will be flexed as far as possible. The other hip will be flexed in the same way. The subject will hold one leg on his chest and let his other leg down until it is flat on the table. If the hip does not extend fully, a flexion contracture of that hip may exist. Repeat the procedure for the opposite leg. Next, the subject is positioned in a supine position so that his knees are able to flex over the plinth. Rectus femoris tightness is indicated if the subject is not able to flex his knee to 90' with the hip maintained in a neutral position.8

8. Ober Test The subject will lie on his side with the leg to be tested uppermost. The leg will be adducted as far as possible and the knee flexed to 90' while keeping the hip joint in the neutral or slight extension position to relax the iliotibial tract. The abducted leg will then be released. If the iliotibial tract is normal, the thigh should drop to the adducted position. If there is a contracture of the fascia lata or iliotibial band, the thigh will remain abducted when the leg is released or compensation will occur in the lumbar spine to allow the leg to a d d ~ c t . ~

9. SI Compression/Distraction Tests The anterior portion of the SI joint is tested with the patient supine. The examiner contacts the ASlS with the heels of both hands. The forearms are crossed, and a posterior-lateral spring is g i~en.~ .~ , ' ' The posterior portion is tested with the subject side lying with hand contact on the anterior-lateral


rim of the ilium. A downward thrust is given. The joint extended by the examiner placing one hand on the flexed being tested is on the top If either of these tests knee joint and the other hand on the ASlS of the opposite elicit pain, it is an indication there is pathology in the side and pressing down on each of these points. If the joint." subject complains of increased pain in the SI joint region,

10. FABERE Test The subject lies supine on the plinth and there may be pathology in the SI joint or hip joint.6 places the ankle of his side to be tested on his opposite 11. Degree of SLR Hamstring length will permit approxi- knee. The hip joint is thus flexed, abducted, and externally mately 70° of hip joint flexion? rotated. To stress the SI joint, the range of motion is

APPENDIX 2-DATA SHEET

subject Number Date Age Sex Service Occupation Leisure Activities Previous back pain or injuries Screening Tests

1. Static Pelvic Exam High Low Level

(R) lliac crest (L) lliac crest

(L) PSIS (R) ASlS (L) ASlS

2. Special Tests Positive on: Standing Flexion Test R L Symmetrical Sitting Flexion Test R L Symmetrical

Test Data DX Date Long Sitting Test R L Malleolus

Supine R L mm longer short to long Sitting R L mm longer long to short

Confirmational Data

Sulci (deep or shallow) R L- Prone Knee Flexion Test to 90°

short leg in extension R L short leg in flexion R L

Sacroiliac Fixation Test PSIS moves

Supplemental Data Hip AROM

Results

superiorly inferiorly no change

Flexion Extension - IR - ER & ADD

Muscle Testing Hip Flexors ~xtensors - IR - ER ABD - ADD Leg Lengths (ASIS to lateral malleolus) R cm L cm . .

R L

Thomas Test Ober Test Degree of SLR (Hamstring Length)

Comments:

R L

Sl Comp/Dis Test FABERE Test R L-

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Validacion Del Long Sitting Test