The Sacrum - Decoded

This 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
 Practice Question #2
• 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?
Answer
 Practice Question #3
• 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?
 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/Treatmen
t_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!