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» Causes of Sacroiliac Joint Dysfunction:
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» Anatomy of Sacroiliac Joint:
o
Sacroiliac joints are weight bearing joints between the articular surfaces of sacrum and ilium.
o
Sacroiliac joints are made up of iliac, sacral auricular surfaces and tuberosities [1,2,3,4,5].
Auricular surfaces from a
synovial joint
, with acapsule and a cavity filled with fluid.
Tuberosities, connected by a interosseous ligament,constitute a fibrous form of a
synarthrosis
.
o
SI joint is reinforced by some of the strongest and most massive ligaments of the body.
o
Ventral Sacroiliac Ligament
•
Assists the symphysis pubis in resisting separation or horizontalmovement of the innominate bones at the SI joint.
•
Palpated at
Baer's SI point
(Point on a line from the umbilicus to theanterior superior iliac spine (ASIS) 5 cm from umbilicus).
•
Stressed using transverse anterior/posterior compression pain provocation test.
•
Weakest among the sacro iliac ligaments.
o
Long Dorsal Sacroiliac Ligament
•
During incremental loading of the sacrum, it becomes tense during
counternutation
(base of the sacrum moves backward) and slackenswith
nutation
(opposite movement of sacrum) [6].
•
Palpated in the area directly caudal to the posterior superior iliac spine(PSIS).
o
Interosseous Sacroiliac Ligament
•
Largest syndesmosis
in the body and functions as the major bond between the bones filling the irregular space posterior-superior to the joint.
•
Resist anterior and inferior movement of the sacrum.
•
Primary barrier to direct palpation of SIJ.
o
Sacrotuberous Ligament
•
Plays significant role in
stabilizing against nutation
of the sacrum, andconteracting against the dorsal and cranial migration of the sacral apexduring weight bearing.
•
Tension increaseswith contraction of Gluteus maximus.
o
Sacrospinous Ligament
•
Along with sacrotuberous ligament, it opposes forward tilting of thesacrum on the hip bone during weight bearing of the trunk andvertebral column.
o
Function of Sacroiliac Ligaments:
♣
Works collectively as a
force transfer
for the hip and trunk muscles, producing innominate and/or sacral movements, in response to inducedforces from the femur and/or vertebrae.
♣
They also help to prevent the following:
•
Craniocaudal dislocation of sacrum
•
Anterior gapping (lateral innominate rotation)
•
Posterior gapping (medial innominate rotation)
•
Hyperflexion (posterior innominate rotation, or mutation)
•
Hyperextension (anterior innominate rotation, or counternutation)
» Facts regarding Sacroiliac Joint:
o
Sacroiliac Joints are
inherently stable
[7,8,9].
o
The joints are designed for
load transfer
[10,11] and can safely transfer enormous compressive forces under normal conditions [9].
o
The sacroiliac joints has
very little movement in non-weight bearing (average2.5 degrees rotation)
[1,12,13,14,15] and even less in
weight-bearing (average 0.2 degrees)
[16].
o
Movements of the SI joint
cannot be reliably assessed by manual palpation
, particular in weight-bearing [16,17,18].
o
Due to its anatomical makeup, intra-articular displacements within the SI joints are unlikely to occur.
o
Distortions of the pelvis observed clinically are likely to occur secondary to
changes in the pelvic and trunk muscle activity
, resulting in direcitonal strainand not positional changes within the SI joints themselves [19].
o
Pain relief from from manipulation is likely to result from
nociceptiveinhibition based on neuro-inhibitory factors and/or altered patterns of motor activity
[20,21].
o
When clinical signs of
reduced force closure have been identified (positive Active SLR)
, the increased movement is identified at the symphysis pubis -not the sacroiliac joints [22].
o
Pain from the sacroiliac joints is located
primarily over the joint (inferior sulcus) and may refer distally
, but not to the low back [23,24,25,26,27,28,29,30].
o
Sacroiliac joint disorders can be
diagnosed using clinical examination
[29,31,32,33,34] which includes finding of pain primarily located to theinferior sulcus of the SI joint, positive pain provocation tests for SI joints andabsence of painful lumbar spine impairment.
o
The SI joint has many muscles that act to compress and control it (forceclosure), thereby enhancing
pelvic stability allowing for effective load trasnfer
via pelvis during a variety of functional tasks[7,8,9,35,36,37,38,39,40,41,42,43,44].
» Motions at Sacroiliac Joint:
Three types of motion are available to the inominate bones:
Symmetrical Motion
- Movement of both innominates as a unitrelation to the sacrum [45,46,47,48].
•
During trunk flexion or bilateral hip flexion, the
sacrumnutates
(rotates anteriorly), so that the promontory movesventrocaudally while the apex moves dorsocranially.
•
This motion is resisted by following structures:
Wedge shape of the sacrum
Ridges & depressions of the articular surfaces
Friction coefficient of the joint surface
Integrity of the interosseous & sacrotuberous ligaments
•
The
sacrum counternutates
, or moves in opposite direction,during trunk extension or bilateral hip extension.
•
This motion is resisted by the long dorsal sacroiliac ligament[6].
•
Combination of rotation and translation is angular movement of the sacrum, during which the iliac crests move closer together while the iliac tuberosities move further apart.
•
Greatest amount of movement, as much as 5.6+/-1.4 mm,occurs when going from recumbent to standing and reverses indirection when moving from standing to recumbent [47].
•
Rotation is accompanied by translation, which results inincreased ligamentous tension and absorption of energy [49].The SI joint thereby function as
shock absorbers
.
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