The concept of the sacroiliac joint (SIJ) as a pain generator is now well established. However, the evaluation and treatment of SIJ dysfunction remains controversial. One issue is the broad categorization and terminology utilized for the anatomical etiologies of the pain by various health professionals. Controversy also exists because of the complex anatomy and biomechanics of the SIJ.
There is no specific symptom or cluster of symptoms, nor any specific examination technique that is both sensitive and specific for the diagnosis of SIJ abnormalities. There are no imaging studies that distinguish the asymptomatic from the symptomatic patient. It can only be diagnosed using local anesthetic blocks. There is currently no gold standard for treatment. In patients with low back pain, the prevalence of sacroiliac pain, diagnosed by local anesthetic blocks, is 15%.The incidence may be even higher in high level sportspeople. One study showed an incidence of over 50% in elite rowers.
Symptoms of Sacroiliac Joint
The SIJ is diarthrodial (synovial anterior and fibrous posterior). Its joint surfaces are reciprocally shaped the reciprocal surface.
- Age changes begin to occur on the iliac side of the joint as early as the third decade. The joint surface irregularities increase with age and seem to be weight-bearing related.
- The capsule becomes more thickened and fibrous with age. SIJ motion is best described as a combination of flexion and extension, superior and inferior glide, and anterior and posterior translation.
- SIJ motion is minimal, with approximately 2.5 degree of rotation and 0.7 mm (0.3 in.) of translation, and it is best regarded as a stress-relieving joint in conjunction with its counterpart and the pubic symphysis.
- In the normal gait cycle, there are combined activities that occur conversely in the right and left in nominate bones, and function in connection with the sacrum and spine.
- Throughout this cycle there is also rotator motion at the pubic symphysis, which is essential to all normal motion through the joint.
- In static stance, when one bends forward and the lumbar spine regionally extends, the sacrum regionally flexes, with the base moving forward and the apex moving posterior.
- During this motion, both in nominates go into a motion of external rotation and out-flaring.
- This combination of motion during forward flexion is referred to as nutation of the pelvis. The opposite occurs in extension and is called counter nutation.
- SIJ dysfunction refers to an abnormal function (e.g. hypo or hyper mobility) at the joint, which places stresses on structures in or around it. Therefore, SIJ dysfunction may contribute to lumbar, buttock, hamstring or groin pain.
The precise etiology of sacroiliac dysfunction is uncertain. Osteopaths describe a number of dysfunctions associated with hypomobility:
- Innominate shears, superior and inferior
- Innominate rotations, anterior and posterior
- Innominate in-flare and out-flare
- Sacral torsions, flexion and extension
- Unilateral sacral lesions, flexion and extension.
Vleeming and colleagues have described their integrated model of joint dysfunction:
- It integrates structure (form and anatomy), function (forces and motor control) and the mind (emotions and awareness).
- Integral to the biomechanics of SIJ stability is the concept of a self-locking mechanism.
- The ability of the SIJ to self-lock occurs through two types of closure: form and force.
- Form closure describes how specifically shaped, closely fitting contacts provide inherent stability independent of external load.
- Force closure describes how external compression forces add additional stability. The fascia and muscles within the region provide significant self-bracing and self-locking to the SIJ and its ligaments through their cross-like anatomical configuration.
Clinical Features of Sacroiliac Joint
The patient with SIJ pain classically describes low back pain. The pain is usually restricted to one side but may occasionally be bilateral.
- SIJ disorders commonly refer to the buttock, groin and poster lateral thigh. Occasionally, SIJ pain refers to the scrotum or labia.
- Broadhurst describes a clinically useful description of pelvic/SIJ dysfunction.
- Clinically, the patient has deep-seated buttock pain, difficulty in negotiating stairs and problems rolling over in bed, with a triad of signs-pain over the SIJ, tenderness over the sacrospinous and sacrotuberous ligaments, and pain reproduction over the pubic symphysis.
- The physical examination should begin by observation of the athlete both statically and dynamically.
- The patient should be evaluated in standing, supine and prone positions, and symmetry assessed in the heights of the iliac spines, anterior superior iliac spines, posterior superior iliac spines, ischial tuberosities, gluteal folds, and greater trochanters, as well as symmetry of the sacral sulci, inferior lateral angles and pubic tubercles.
- Leg length discrepancy should be assessed.
- True leg length discrepancies will generally cause asymmetry and pain, whereas a functional leg length discrepancy is usually the result of SIJ and/or pelvic dysfunction.
- Dynamic observation may reveal a decrease in stride length with walking, leading to a limp, or a Trendelenburg gait due to reflex inhibition of the glutens medius.
- Muscle strength and flexibility should be assessed. Full assessment of the hips and lumbar spine should also be performed.
- The presence of trigger points in surrounding muscles, particularly glutens medius, should be noted. Palpation over the SIJ may reveal local tenderness.
- Numerous clinical tests have been described to assess SIJ function, but none have proven reliable.
- Some of the more popular tests include standing and seated flexion tests, the stork test and Patrick (Faber) test.
- There is no specific gold standard imaging test to diagnose SIJ dysfunction due to the location of the joint and overlying structures that make visualization difficult.
Treatment of Sacroiliac Joint
Due to the complex nature of the SIJ and its surrounding structures, treatment must focus on the entire abdomino-lumbo-sacro-pelvic-hip complex, addressing articular, muscular, neural and fascial restrictions, inhibitions and deficiencies.
- Core stability training should be included. A recent study has suggested that the clinical benefits incurred with training the transversus abdominis muscle may be due to significantly reduced laxity in the SIJ.
- Exercise rehabilitation is an integral part of recovery from SIJ dysfunction.
- Pelvic or SIJ dysfunction should be considered with the lumbar spine in any program designed to improve the overall control of the lumbo pelvic area.
- Stretching and soft tissue therapy is useful in correcting pelvic/SIJ imbalance.
- The most common soft tissue abnormalities found with unilateral anterior tilt are tight psoas and rectos femoris muscles.
- A technique to reduce psoas tightness.
- Muscle energy techniques may also be helpful, as may osteopathic manipulation. Sacroiliac belts have not been shown to be particularly helpful.
- If these manual techniques fail to control the sacroiliac pain, injection therapy may prove useful.
- A combination of local anesthetic and corticosteroid agents may be injected into the region of the SIJ, either with or without fluoro- scopic guidance.
- Sclerosants are occasionally used when hyper mobility is present, sometimes referred to as prolotherapy.
- Precipitating factors for the development of SIJ disorders may include muscle imbalance between the hip flexors and extensors or between the external and internal rotators of the hip, leg length imbalance and biomechanical abnormalities, such as excessive subtalar pronation.
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