Mechanical Connections: Talus to Sacrum

As I work through my current academic semester at the Canadian Academy of Osteopathy I am confronted with a lot of work and little time to dedicate to anything else…which is perfect! I continue to look for information worth sharing so here I go – while listening to an anatomy lecture I had (to me at least) an interesting epiphany, the fibular head has the possibility to affect the sacrum.

First I will say that the fibular head has been described as prone to dysfunction via dysfunctions of the talus – one does not occur without the other. Now, also consider the structures that attach to the fibular head – the soleus (which extends down to the calcaneus via the achilles tendon that will also have relations to talar dysfunctions), the fibular collateral ligament, and the biceps femoris. The soleus also has attachments to the tibia which helps to begin highlighting how a fibular head dysfunction relates to knee dysfunction – do not stop here in your thought process though!

The next step in the line I am attempting to draw takes us up the biceps femoris to the ischial tuberosity. How do we get to the sacrum from the ischial tuberosity – the sacrotuberous ligament.

Now that we have gone from the talus to the sacrum along a primarily soft tissue line it is time to begin the practical thought process. The sacrum sits between the innominates and the ischial tuberosity is part of the innominate. The force transfer runs from the sacrum to the ischial tuberosity via the sacrotuberous ligament, both of which are highly affected by innominate dysfunction. From the innominate dysfunction there will be a mechanical alteration at the attachment site of the biceps femoris leading to an altered mechanical strain on the fibular head to then transfer altered force to the talus. There are a myriad of other connections here that all count – if there is an issue at the ischial tuberosity there will also be affects directly to the semitendinosus and semimembranosus beginning an altered pattern of strain through the knee in conjunction with the biceps femoris. Again, do not stop your thinking here – if the ischial tuberosity is malpositioned so is the rest of the innominate leading to altered lines of force through the quadriceps, adductors, pelvic floor, psoas and iliacus, quadratus lumborum, the abdominal group, the latissimus dorsi, as well as the erector mass.

Now that I have wandered around connections through the innominate I need to circle back and speak about the sacrum to talus line (it is after all what I am supposed to be talking about!). Correction of the talus is not completely feasible without correcting to the root of the force line. Without getting caught up in sacral lesioning or anything else I want to stress the basic principle of treatment – start from the base and work up and down, then work from the center out. The base is always the pelvis. The leg hangs from the pelvis and the foot hangs from the leg. Regardless of the etiology – a lesion that started at the foot via an injury or a sacral lesion – there is an alteration in the line of force that requires the correction begin at the base. Correct any pelvic lesioning to alter the mechanics and then work proximal to distal. By correcting the pelvic lesion there will be a sacral correction and a correction to the ischial tuberosity which then corrects the line from the biceps femoris to the fibular head, then to the soleus (don’t forget about fibularis longus and brevis as additional soft tissue connections), and then down to the talus (and the calcaneus via the soleus). Any issues that are left after the pelvis is truly corrected may be treated then.

For me this is an exercise in affirming the principles of treatment via a superficial anatomical line. I am doing as Dr. Still said to do, I am digging (albeit superficially at the moment – to get deeper in to the related issues neurology and vasculature must be considered as well). I am attempting to take the time now to draw the lines so that I may treat in a rational fashion.

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3 thoughts on “Mechanical Connections: Talus to Sacrum

  1. The body IS a unit after all!
    There’s actually a really great 2 person BLT innominate spread where you then lever from the fibular head. There’s also the MET where the hamstrings are used to lever the coccyx (which you must conclude would access the Sx) to correct a torsion. While I certainly feel that the bottom (talus) up approach is valid and often accurate, I’m finding that biceps fem can be quite the trickster!

    • The body is definitely a unit! My intention is not to suggest a direction of treatment as much as to suggest recognition of the unity via mechanical lines. In principle I would never start from the talus as its lesions require correction from the root of the mechanical line. The leg is subject to primarily compression based issues (aside from traumatic injury) and that compression will alter the base (the pelvis). Generally speaking, removing mechanical strain from the leg is efficiently accomplished by long lever correction of the pelvis with whatever activating force is most appropriate for the lesion that presents itself. For myself (the only person I can speak for!) I find that removing lesions from the most proximal point first makes correction of distal structures more efficient. If the biceps femoris is causing trouble it may be appropriate to correct it from the root (the innominate) by any effective means and then move down. I get way too long winded when I speak about Osteopathy! I defer to Dr. Still at all times – especially (in my hopefully accurate paraphrasing) he said that different Operators will use different methods which is acceptable as long as the intended result occurs appropriately (again, I apologize for my poor paraphrasing).

  2. It is not uncommon for a new patient to present complaining of sacroiliac pain. When i do assessment, it is also not uncommon to find that one of the ankles is quite restricted – usually it will not evert/pronate well, because the fibula was pulled inferiorly onto the talus during the original injury, when the foot/ankle was overly inverted/supinated. Very often this is an old injury and the patient will have forgotten about it till you ask them whether they “have ever really sprained this ankle at some time – even a long time ago?”, and invariably they will remember twisting/injuring their ankle, either months ago, or years ago, and have a story about how long they were hobbling around. If the fibula has been pulled inferiorly, it will put a drag on the sacrum another way than the one you describe: the IT band has insertion on the proximal head of the fibula, originates from the inferior portion of the gluteus maximus, and the medial border of the gluteus maximus inserts on the lateral border of the sacrum. I find that by re-seating the fibula (moving it superiorly), the foot/ankle can find their normal position and regain normal movement, and the drag on the sacrum from the IT band/gluteus maximus is removed. Since the fibula was the primary lesion, when it is corrected, the stress is taken off the sacrum, and it can find its own balance again. I have treated this condition (sacroiliac pain) many times successfully without even touching the sacrum (or anything north of the knee), where the old ankle injury and its resultant displacement of the fibula was the primary lesion.

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