Sacroiliac (SIJ) Dysfunction

The SIJ is not a ‘single entity’

It has an integral relationship to whole kinematic chain (affects the whole body).

It is responsible for force/load transfer from the lower limb to the spine and from the spine to the lower limb.

Functional activities can have an adverse effect on this joint

(Vleeming et al 1989)

Functional activities such as throwing, bowling, sitting, driving, prolonged vibration of the pelvis, stepping off a height, getting foot caught in stirrup on a horse all have been shown to produce adverse effects in this joint.

Joint itself is derived from first three sacral vert. It is L shaped in nature. Has a short vertical and a longer horizontal arm. Movement occurs as glides along these surfaces.

The Iliac surface is first to show degeneration by the 3^rd decade and the Sacral surface shows degeneration in the 4th and 5th decades.

Sturesson et al (1989 & 1999) demonstrated that mobility is possible & it is essential for shock absorption: There was found to be Angular Range of movement of between  1- 4° coupled with linear translation of less than 2mm.

Vleeming et al (1992) found that mobility was retained with age and not lost.

Buyruk et al (1997) performed doppler studies of SIJ and these revealed symptomatic SIJ’s had asymmetry in stiffness/motion.

Movement of the joints:

Nutation:

The superior aspect of the sacrum moves forward into the pelvis,

This is the closed packed position of the SIJ.

Counternutation:

The superior aspect of the sacrum moves backwards,

This is a more “unstable”/loose packed position.

Sacral nutation tightens:  –

Sacrotuberous ligament, Sacrospinous ligament, Iliolumbar ligaments.

Stability of the SIJ:

2 important muscle groups contribute to the stability of pelvis & lumbar spine

1) The inner unit (core/local stabilizers)

Pelvic floor, Transversus abdominis, Multifidus, diaphragm & Psoas

2) The outer unit (sling systems)

Anterior & Posterior oblique slings; Longitudinal & Lateral slings:

The patterning of muscle activation & co-ordination of muscle action ensure optimal stability & load transference in the SIJ.

Causes of SIJ dysfunction:

Trip/ slip

Sports/landing

Fall onto buttock

RTA - knees hit dashboard, or braked hard on impact

Overstretch during sport (football kick etc.)

Leg caught in stirrup

Ergonomic asymmetry/misuse

Last trimester of pregnancy

Symptoms:

Unilateral (one sided) symptom distribution

Pain can refer pain to the leg, groin, iliac crestand/or genitals.

As the sciatic nerve is close to the sacrotuberous ligament and the piriformis pain can go down the leg past the knee also.

There will be poor standing balance unilaterally

Pain can be potentially provoked by:

Turning in bed

Getting in/out car; bath; bed

Climbing stairs

Menstruation

Going from a sitting to a standing position

Asymmetrical sitting: crossing legs

Prolonged standing or sitting

Incidence:

Link to lower back pain (LBP):

Cibulka et al (1992) – 12% of LBP patients had SIJ dysfunction.

Waddell G (1998) - 13% of persistent LBP patients have SIJ dysfunction.

Bernard and Kirkaldy-Willis (1987) – 22.5% of LBP = SIJ dysfunction.

Diagnosis:

No one element can diagnose SIJ dysfunction:

Check the position of the following:

Ilia:

(PSIS, ASIS, Iliac crest levels, Pelvic angle, skin creases & shift, Symphysis pubis)

Sacrum:

ILA (Inferio-Lateral Angle), Sacral Sulcus

Lumbar spine :

Spinous & Transverse Processes

Leg length:

Check the movement of the joint:

Piedallu’s Sign

Standing Forward Flexion Test (Vincent-Smith & Gibbons 1999)

Gillet test (‘ipsilateral kinetic test’)/Stork Standing Test (Meijne et al 1999):

Active SLR- with ant compression- TA

Ant pelvic floor- hook up

PSIS- multifidus

Ischial tuberosities-post pelvic floor

SI Fixation Test

Drop test: Provocation test for pain, patient stands on one foot, raises the heel then lowers back down

Distraction (to anterior SIJ)

Thigh Thrust (posterior shearing force to SIJ)

Gaenslen’s Test (posterior & anterior rotational forces to SIJ)

Compression:

Sacral Thrust (anterior shearing force of sacrum on ilia)

Faber 4/Patrick’s Test

3 positives indicative of SIJ dysfunction (Inter-rater reliability (k=0.52-0.88))

Classification of SIJ dysfunction:

Ilio-sacral dysfunction:

Anterior/posterior tilt

Upslip

In/out flair

Pubic Symphysis dysfunction

Sacro-ilial/lumbar dysfunctions:

Torsions (FST/sacral or BST/lumbar

Advice:

Need to maintain correct alignment for 6 weeks

No Asymmetrical Postures (sitting at home & work/standing/lying)

No Asymmetrical activities (stairs, reaching, in/out car/bed, child care; sports)

Home exercise/maintenance program (muscle inhibition/facilitation, joint mobs)

Home exercises:

Gluts and lat dorsi

Bridge- push with R arm and up with L leg

Lunging  with foot on stool increase pelvic tilt

Pelvic tiliting

Segmental movement

Clams:

Multifidus- in step standing, can add elevation of arms

Obviously diagnosis of the Sacroiliac joint can be difficult so if you are unsure then book in to see your Physiotherapist

If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866195914

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