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OMM / OPP — Osteopathic Manipulative Medicine

Sacral Somatic Dysfunction

Torsions, flexion/extension, and the findings that make them stick.

Quick — patient has positive seated flexion test on the RIGHT, deep sacral sulcus on the RIGHT, and a posterior/inferior ILA on the LEFT. Which torsion?

Forward vs Backward — The Split That Matters

Forward Torsion
L-on-L • R-on-R
Rotation letter = axis letter
Spring test: NEGATIVE
L5: Neutral (Type I)
Backward Torsion
L-on-R • R-on-L
Rotation letter ≠ axis letter
Spring test: POSITIVE
L5: Flexed/Extended (Type II)
🛇
NEGATIVE
Sacrum springs = forward torsion
L-on-L or R-on-R
🛑
POSITIVE
Sacrum resists = backward torsion
L-on-R or R-on-L
⚡ Spring test is the fastest differentiator. Negative = forward. Positive = backward. Learn this first, everything else slots in.

The Four Sacral Torsions

Tap a tab. Watch the sacrum shift. Notice which side goes deep vs shallow.

Forward Torsion
Left Rotation on Left Oblique Axis
LEFT RIGHT OK DEEP POST INF OK L rot SFT +R
Left Sulcus
Shallow (normal)
Left ILA
Posterior & Inferior
Right Sulcus
DEEP (anterior)
Right ILA
Shallow (normal)
Seated Flexion Test
Positive on RIGHT
Spring/Sphinx Test
NEGATIVE
L5 Diagnosis
Neutral, Sidebent LEFT, Rotated RIGHT
Type I (Fryette's 1st law): SR opposite directions
🔧
Muscle energy: Modified left lateral recumbent (axis side DOWN), chest toward table. Flex hips to lumbosacral junction, suspend legs off edge. Patient lifts legs toward ceiling against resistance, 3-5 reps.
Forward Torsion
Right Rotation on Right Oblique Axis
LEFT RIGHT DEEP OK OK POST INF R rot SFT +L
Left Sulcus
DEEP (anterior)
Left ILA
Shallow (normal)
Right Sulcus
Shallow (normal)
Right ILA
Posterior & Inferior
Seated Flexion Test
Positive on LEFT
Spring/Sphinx Test
NEGATIVE
L5 Diagnosis
Neutral, Sidebent RIGHT, Rotated LEFT
Type I (Fryette's 1st law): SR opposite directions
🔧
Muscle energy: Modified right lateral recumbent (axis side DOWN), chest toward table. Flex hips, suspend legs off edge. Patient lifts legs toward ceiling against resistance, 3-5 reps.
Backward Torsion
Left Rotation on Right Oblique Axis
LEFT RIGHT SHLW OK OK POST INF L rot SFT +L
Left Sulcus
SHALLOW (posterior)
Left ILA
Shallow (normal)
Right Sulcus
Normal
Right ILA
DEEP (posterior & inferior)
Seated Flexion Test
Positive on LEFT
Spring/Sphinx Test
POSITIVE
L5 Diagnosis
F/E, Sidebent RIGHT, Rotated RIGHT
Type II (Fryette's 2nd law): SR same direction
🔧
Muscle energy: Modified right lateral recumbent (axis side DOWN), chest AWAY from table. Extended hips. Legs hang off edge. Patient lifts legs toward ceiling against resistance, 3-5 reps.
Backward Torsion
Right Rotation on Left Oblique Axis
LEFT RIGHT OK SHLW POST INF OK R rot SFT +R
Left Sulcus
Normal
Left ILA
DEEP (posterior & inferior)
Right Sulcus
SHALLOW (posterior)
Right ILA
Shallow (normal)
Seated Flexion Test
Positive on RIGHT
Spring/Sphinx Test
POSITIVE
L5 Diagnosis
F/E, Sidebent LEFT, Rotated LEFT
Type II (Fryette's 2nd law): SR same direction
🔧
Muscle energy: Modified left lateral recumbent (axis side DOWN), chest AWAY from table. Extended hips. Legs hang off edge. Patient lifts legs toward ceiling against resistance, 3-5 reps.

The Pattern That Makes It Click

💡 In torsions, findings are on OPPOSITE sides (deep sulcus one side, posterior ILA the other). In unilateral dysfunctions, they're on the SAME side. This alone eliminates half the differentials.
⚡ Seated flexion test is positive on the OPPOSITE side of the deep sulcus in forward torsions — and on the SAME side as the shallow sulcus in backward torsions. 🔑 SFT finds the dysfunction side — the side where things aren't moving right.
L5 ALWAYS follows these rules in torsions:
1. Sidebends TOWARD the oblique axis
2. Rotates OPPOSITE the direction of sacral rotation
3. Forward = Neutral (Type I), Backward = F/E (Type II)
Practice the L5 derivation step-by-step →

Elimination Game

Reveal clues one at a time. Each clue eliminates torsions. Last one standing wins.

Patient: Low back pain for 3 days after shoveling snow. Osteopathic structural exam reveals the following findings. Reveal them one by one.
L-on-L
Forward
R-on-R
Forward
L-on-R
Backward
R-on-L
Backward

All Sacral Dysfunctions (Visual Reference)

Every dysfunction at a glance. Green = forward, red = backward, purple = unilateral, blue = bilateral.

L-on-L Torsion
SFTRight +
SulcusR deep
ILAL post/inf
SpringNegative
L5N, SL, RR
R-on-R Torsion
SFTLeft +
SulcusL deep
ILAR post/inf
SpringNegative
L5N, SR, RL
L-on-R Torsion
SFTLeft +
SulcusL shallow
ILAR deep
SpringPositive
L5F/E, SR, RR
R-on-L Torsion
SFTRight +
SulcusR shallow
ILAL deep
SpringPositive
L5F/E, SL, RL
L Unilateral Ext
SFTLeft +
SulcusL shallow
ILAL deep
SpringPositive
R Unilateral Ext
SFTRight +
SulcusR shallow
ILAR deep
SpringPositive
L Unilateral Flex
SFTLeft +
SulcusL deep
ILAL shallow
SpringNegative
R Unilateral Flex
SFTRight +
SulcusR deep
ILAR shallow
SpringNegative
Bilateral Extension
SFTNegative
SulcusBoth shallow
ILABoth deep
SpringPositive
Bilateral Flexion
SFTNegative
SulcusBoth deep
ILABoth shallow
SpringNegative
📋 Quick sort: Same-side findings = unilateral. Opposite-side findings = torsion. Both sides = bilateral. SFT negative = bilateral.

Quiz: Sacral Patterns

4 patients just walked in. You've got their exam findings. Don't overthink it — use the patterns.

Bone Wizardry — Sacral Somatic Dysfunction / OMM