The Sacrum - DecodedThis guide will give you the tools to succeed on

the written exam.Use this knowledge to “calculate” the sacral diagnosis in your head during the practical.

Step 1: Spring Test

• The normal, non-pathological state of the Sacrum is FLEXED

• A FLEXED sacrum is Nice Normal and Negative on a spring test. So, you will feel a spring.

• An EXTENDED sacrum is Painful Posterior and Positive on a spring test. So you fill be pushing against a barrier.

• When diagnosing a sacrum, first do a spring test!

Spring Test Results & Possible Diagnoses

(-) Flexed (+) Extended• Left on Left• Right on Right• Left Unilateral Sacral Flexion• Right Unilateral Sacral Flexion• Bilateral Sacral Flexion

• Left on Right• Right on Left• Left Unilateral Sacral Extension• Right Unilateral Sacral Extension• Bilateral Sacral Extension

So, when you determine the spring test, you can focus on your top 5 possible diagnoses. On an exam, if answers A, C and E are impossible based on your spring test, cross them out. This way you’ve improved your chances of getting the right answer…however, you can do 2 more simple steps to be certain.

Step 2: Evaluate For Deep Sulcus

• On test day, document your result on the following diagram.

Left Right

Example

• Let’s say you found a deep sulcus on the right.• Document it as…

Step 3: Evaluate for Posterior ILA

• On test day, document your result on that same diagram. For example…you find that deep sulcus on the right and a left posterior ILA.

A Note About Naming

• Sacral diagnoses are named “____ on ____”• The first blank is named after the side of the ILA. • So, the previous image would be a “Left on ____”• The second blank is named after the AXIS.• The axis is determined based on the SPRING TEST.

Finding the Axis• In a NEGATIVE SPRING TEST, the Sacrum is flexed

and the axis is OPPOSITE the side of the deep sulcus.• In a POSITIVE SPRING TEST, the Sacrum is extended

and the axis is on the SAME side as the deep sulcus.• So, based on our example, if our spring test were (-)

the diagnosis would be “Left on Left” or if our spring test were (+) the diagnosis would be “Left on Right”

• Let’s see what that looks like…

Completed Example

(-) Spring Test (+) Spring Test

Diagnosis: Left on Left Diagnosis: Left on Right

Got it?

• Good!• Test your knowledge on the following mock

exam questions. • Read the questions thoroughly and draw a

diagram on a piece of paper to figure out your diagnosis. Then, compare your diagram and answer to the key on the next page.

Practice Question #1

• Jane is a 45 year old cafeteria employee. She presents with pain after completing a long shift. On exam, you find a deep sulcus on the right, a negative spring test and a posterior ILA on the left.

• What is the diagnosis?

Answer

• Carl is a 54 year old detective presenting with low back pain following an altercation with a criminal. You assess the sacrum and find the following: Positive spring test, deep sulcus on the right, posterior ILA on the left.

• What is the diagnosis?

Practice Question #2

Answer

• Hugh is a 47 year old pathologist presenting with a bit of a hobble after sitting all night examining slides. On examination of his sacrum, you detect: Deep sulcus on the Left, Negative spring test, posterior ILA on the Right.

• What is your diagnosis?

Practice Question #3

Answer

Diagnosis: Right on Right

Practice Question #4

• Samantha is a 23 year old G2P2 presenting for 6 week post-partum follow up. She complains of persistent low back pain. On examination of her sacrum, you detect: Spring test positive, sacral bases are even, but a little shallow. The ILAs are symmetrical as well, but a little more anterior than you’d expect.

• What is the diagnosis?

Answer(+) Spring Test

Diagnosis: Bilateral Sacral Extension

Note: When your question doesn’t fit the standard “deep sulcus here, posterior ILA there”, then start to think about Unilateral and Bilateral pathologies.

Practice Question #5

• Claire is a 17 year old who fell off a banister while dancing to kill time during Saturday school. She presents with a normal gait, but grimaces when you palpate her low back. On sacral exam, you find: Negative spring test, deep sulcus on the right, posterior ILA on the right.

• What is the diagnosis?

Answer(-) Spring Test

Diagnosis: Right Unilateral Sacral Flexion

Okay…

• Unilateral Sacral Findings follow a special rule• If there is a Negative Spring Test, the sacrum is

flexed and the Unilateral Flexion is associated with a deep sulcus and posterior ILA on the effected side, like in the previous example.

• However, with a Positive Spring Test, you will find the deep sulcus and posterior ILA OPPOSITE the extended side. For example…

Unilateral Extension Example

• Jane is a 14 year old girl who took a bad spill off a balance beam and now has pain when standing at the bus stop every morning, but it gets better when she sits on the bus. On exam, you find: Spring test positive, deep sulcus on the right, posterior ILA on the right.

• What is your diagnosis?

Answer(+) Spring Test

Diagnosis: Left Unilateral Sacral Extension

Note: Yeah, this one is still a bit of a head scratcher, but look to page 37 of this document for more info: http://members.nata.org/virtuallibrary/sacroiliac/pdfs/PowerPoint_Presentations/Treatment_of_Sacroiliac_Joint_Dysfunction.pdf

Note:

• When you learn Cranial, sacral flexion will be referred to as “Anterior Nutation” or just “Nutation” and extension will be referred to as “Posterior Nutation” or “Counternutation”.

• It’s silly but there you go.

The Power Is Yours

• After this, you should be up to any sacrum question they throw at you.

• You’ll see these kinds of questions all the way through COMLEX Step 3.

• Best of Luck!