Proactive physiotherpay

Sacroiliac joint dysfunction (SIJD) is a common cause of LBP occurring in 16–30% of patients with LBP. The sacroiliac joint is a diarthrodial synovial joint comprising an anterior segment, which is a true synovial joint, and the posterior segment, a syndesmosis comprising the gluteus minimus and medius muscle, piriformis muscle, and sacroiliac ligament. As all these muscles are shared with the hip joint, the sacroiliac joint (SIJ) cannot function independently. Furthermore, the ligamentous structures and the muscles influence the stability of the SIJ. The nerve supply for SIJ is mainly by the sacral rami dorsal.

The sacroiliac (SI) joint is formed by the articulation of the pelvis and the sacrum.  Dysfunction of this joint can result from how the pelvis impacts on the sacrum or how the sacrum impacts on the pelvis.  If the pelvis (ilium) is responsible for a fixated (immobile/stuck) SI joint, then it is called ‘iliosacral dysfunction’.  If the sacrum is responsible, it is called ‘sacroiliac dysfunction’.

Recent interest in rehabilitation involving the SI joint may be attributed in large part to the fact that approximately 20-30% of low back pain and referred pain comes from the SI joint itself and/or the surrounding ligaments, muscles and other soft tissues involved in the functioning of the joint  (Maigne et al, 1996, Schwarzer et al, 1995).

The concern in sports medicine relates primarily to the problems caused by the biomechanical changes inherent to the malalignment: specific sports injuries, impaired recovery from injury, and a failure of athletes to realize their full potential (Schamberger, 2002).

Sacral Motion and Dysfunction

When you forward bend, your sacral base moves in a posterior and slightly superior direction.  When you bend backward, your sacral base moves in the opposite direction, anteriorly and inferiorly.  The anterior and posterior movement of the sacral base is called nutation and counternutation, but many practitioners use the terms anterior nutation and posterior nutation.  “Nutation” means “nodding.”

Sacrum are also capable of side-bending and rotating.  If there are no joint fixations, then this is what your sacrum does in walking (or running) as you shift your weight from one leg to the other.  Most experts agree that the sacrum only exhibits ‘Type 1’ motion, meaning that side-bending and rotation are coupled to opposite sides (right rotated and left sidebent is known as ‘right torsioned’, left rotated and right sidebent are known as ‘left torsioned’).

The combination of side bending and rotation is also known as ‘torsion.’ When the sacral base is ‘right rotated’ the right sacral base is posterior in relation the left sacral base, and vice versa.  If during an evaluation, you find that the sacral base is rotated (on either side) when you are in the neutral position (standing on two feet), then it is probably dysfunctional.

For instance, if an SI joint evaluation reveals that (in a neutral position) the sacral base is fixated on the right side, then you must determine whether the right sacral base is fixated in anterior or posterior nutation.  Making the correct diagnosis is essential because you must treat the fix side to correct the dysfunction.  Treating the non-fix side will be meaningless.

Why is this important to know?

In cases of pelvic dysfunction, the side that hurts is often the side of the symptom (pain), but not the side that is fixed.  Most practitioners will try to treat the symptomatic side instead of the fixed side. There is a high probability that they will not be the same, and as stated previously, this work will be relatively meaningless.

Hip (Ilium) Motion and Malalignment

When we walk or run our hips rotate reciprocally in all three planes of motion.  These are the ‘sagittal plane’, the ‘coronal’ plane, and the ‘transverse’ plane.  In the sagittal plane, a type of hip rotation (malalignment) occurs as anterior or posterior rotation.  In the coronal plane, a type of hip rotation occurs as upslip or downslip (this is also known as superior or inferior shear, respectively).  In the transverse plane, a type of hip rotation occurs as inflare or outflare (this is also known as medial or lateral rotation, respectively).

If you discover an iliosacral fixation, at first you will only know the side of the fixation.  You must then determine the type of malignment involvement wheather it is anterior/posterior rotation, inflare/outflare, upslip/downslip.  Occasionally, an individual will present with a single malalignment.  Typically, an individual presents with a combination of two malalignments. A triple combination is possible, but relatively rare.

Remember again, you must treat the fixed side.even if the contralateral side is the symptomatic side.  In the case of a single-type of malalignment, just go ahead and treat according to the appropriate technique.  In the case of a combination of malalignment types, you must treat with the appropriate techniques(s), but also in the correct sequence.  The correct sequence is critical because if your sequence is wrong, your work will be ineffective.

After you release the fixed side, you can treat the symptomatic side (especially if they are not the same side) to speed up the healing process on that side.  This healing process will probably happen on its own but may happen faster with treatment.  Again, the sequence is the key.

EVALUATION AND CORRECTION :

The passive straight leg raising test is most helpful in the evaluation of pain in the low back. Pain down the leg on passive straight leg raising, which is exacerbated by dorsiflexion of the foot, is indicative of sciatic nerve pain. Despite a study to the contrary by Danforth and Wil~on,’~ several researchers have found a relationship between sciatic nerve pain and pain in the sacroiliac joint.When the leg is raised, the pull of the hamstrings on the innominate bone causes a posterior torsion strain on the same side.

If this does not increase the pain in the back or if it eases the pain in the back, anterior dysfunction should be suspected. If passive straight leg raising causes pain or increases the pain on the same side, suspect a posterior or vertical complication.

Rationale:

The use of ‘direct’ techniques in treatment, the more effective the results will be.  The use of indirect techniques, however, usually indicates less than a full grasp of the biomechanical descriptions and how to more precisely locate and treat the joint fixation.

Knowing what you are releasing in a client’s body adds to your clarity of purpose and makes you a more effective therapist. The techniques you apply will be more effective than if you don’t know precisely what you are releasing.

 Knowing and naming what you are working on is an essential part of effective therapy.

Reference :

  1. Maitland, J.  Spinal Manipulation… 2001.  North Atlantic Books, Berkley, California.
  2. Schamberger, W. The Malalignment Syndrome, Implications for Medicine and Sport.  2002.  Elsevier Science Limited.
  3. Maigne J-Y, Aivalikis A, Pfefer S.  Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain.  Spine 1996; 21: 1889-1892.
  4. Schwarzer AC, Aprill CN, Boduk N.  The sacroiliac in chronic low back pain.  Spine 1995; 20:31-37.
  5.  Bernard TN, Jr, Kirkaldy-Willis WH: Recognizing specific characteristics of nonspecific low back painClin Orthop Relat Res, 1987, (217): 266–280.
  6. Erhard R, Bowling R: The recognition and management of the pelvic component of low back and sciatic painJ Am Phys Ther Assoc, 1977, 2: 4–15.
  7. Image coutsey :wikipedia

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