The patient appeared well-nourished, mesomorphic, and in excellent health. Early in the day, he had a normal-to-anterior posture and walked with a slight shuffle, but with a symmetrical heel-toe gait. Hyperlordotic and kyphotic spinal features were not present. Later in the day, after sitting for a prolonged period, the patient had trouble standing erect unassisted. In addition, his right leg became flexed and internally rotated, and his gait became anteriorly deviated with limited forward step on the left and an internally rotated step on the right.
During the structural examination, the standing flexion test
8-11 was positive for iliosacral dysfunction on the right, and the seated flexion test
8-11 was positive for sacroiliac dysfunction on the left. Thomas test,
8 performed with the patient in a supine position, was positive for psoas shortening. The patient was unable to extend his right leg beyond 160 degrees (flexion deformity). Tissue tenderness and ropiness were palpable along the right iliopsoas from the point of its insertion on the femur, and proximally through the belly of the muscle, superior to the inguinal ligament. Right anterior superior iliac spine (ASIS) was 2 cm inferior to the left ASIS, and the right posterior superior iliac spine (PSIS) was 1 cm superior to the left PSIS. Superior sacral sulcus was deep on the left, shallow on the right; inferior sacral sulcus was deep on the left and shallow on the right. Motion (springing) of the left sacral base and limited motion of the right sacral base were present. Lumbar vertabra 5 (L5) was sidebent right and rotated left. The medial malleoli were compared and found to be equidistant from the pelvis. The greater trochanteric and iliac crest heights in the standing position were compared with no appreciable discrepancy noted. After osteopathic evaluation was complete, the initial differential diagnoses were chronic psoas syndrome, right anterior innominate rotation, and forward sacral torsion on a right oblique axis (ie, right-on-right torsion).