SI JOINT MOBILIZATION TECHNIQUES

TherapyProtocols

JOINT MOBILIZATION TECHNIQUES FOR SACROILIAC JOINT DYSFUNCTION

Sagar Naik, PT, Dr. Saravanan, Dr. Prerana, Dr. Bhargav Desai
1) Pelvic Shift: Forward & Backward Patient Position: Sitting on the treatment table or bolster with the legs abducted. Arms may be positioned on the operators head or shoulders to facilitate upper thoracic flexion with lumbar extension. Therapist Position: Sits on the floor or a mat or stool in front of the patient.

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A Pelvic Shift Forward

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B Pelvic Shift Backward Motion: With hands on the posterior aspect of the pelvic girdle, therapist shifts the pelvis forward and backward into its end range. Advantages: General mobilization of pelvic girdle as well as increases the extensibility of the inferior hip joint capsule. 2) Self Mobilization of Sacroiliac Joint Patient Position: Kneeling on a table, close to the edge, with the trunk supported on the hands (elbows extended) or on the elbows.

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One leg is shifted to hang the flexed knee over the edge of the table, with the foot supported over the heel of the other leg.

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Motion: The patient relaxes so the pelvis slopes obliquely down from the ilium. The slack is taken up at the SIJ of the supported side on the table. Once the patient senses tension in the joint, very small downward vertical springing motions are performed with the knee over the edge of the table, thus mobilizing the SIJ on the supported side. Advantages: Mobilization of side bending and rotation of the lower lumbar spine are also achieved by this technique.

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3) Forward Rotation for Posterior Iliac Dysfunction For posterior innominate rotation dysfunction, signs on the involved side are as follows: Inferior and posterior PSIS Superior and anterior ASIS Positive Standing Flexion Test Apparent shortening of leg in supine Hypermobility or restriction in innominate anterior rotation

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Patient Position: Supine with the leg on the side to be mobilized extended over the edge of the table. Therapist Position: Stands opposite of the side to be mobilized. The patient or therapist flexes and stabilizes the opposite leg.

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Motion: Place the caudal hand over the thigh and use it to push the hip into further extension; the cephalic hand can be applied to the patient's PSIS, pushing upward to increase the forward rotation of the innominate on the sacrum. Advantages: Technique can be modified to use muscle correction, which can place an anterior rotatory moment on the innominate (muscle energy) using the iliopsoas as the desired force. Have the patient push the freely hanging leg up against your hand with a submaximal force while you give unyielding resistance to the contraction for 7 to 10 seconds. This procedure is repeated three or four times or until all the slack is taken up.

4) Self Mobilization to counteract Posterior Iliac Dysfunction Self treatment technique to counteract posterior iliac dysfunction consists of passive hip extension in prone or supine. Prone:

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Supine:

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In the supine correction technique it is important that the (left) leg is off the table. The hip should be maximally adducted and literally be suspended above the horizontal by the hip capsule and soft tissue. This position should be held for about 2 minutes.

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5) Backward Rotation for Anterior Iliac Dysfunction For posterior innominate rotation dysfunction, signs on the involved side are as follows: Superior and anterior PSIS Inferior and posterior ASIS Positive Standing Flexion Test Apparent Lengthening of leg in supine Innominate Posterior rotation Patient Position: Supine with the leg opposite to the side to be mobilized hanging over the edge of the table. Therapist Position: Stands on the side to be mobilized.

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Motion: The therapists cephalic hand cups the ASIS in the palm while the caudal hand grasps the ischial tuberosity. Transfer your weight toward the patient's head; this results in a backward rotation of the innominate on the sacrum. Advantages: Technique can be modified to use muscle correction, which can place a posterior rotatory moment on the innominate (muscle energy) using the gluteus maximus as the desired force. Have the patient resist a force provided by your trunk (or against the patient's own hands, which fixates the knee) with a sustained submaximal contraction for 7 to 10 seconds. This is repeated three or four times, not allowing the hip to move into extension, only flexion.

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6) Self Mobilization to counteract Anterior Iliac Dysfunction Self treatment technique to counteract anterior iliac dysfunction consists of following techniques: Standing:

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The patient places the foot on a table or bench, leans toward the knee, and stretches it into the axilla. Repeat this exercise several times a day and always making a correction when going to bed to relieve the strain on the involved ligaments. These techniques are powerful rotators of the innominate and can be overdone unless specific guidelines are given. Supine:

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Standing Bending Forwards:

Method to correct right anterior rotation: a right posterior lever effect can be created by resting right foot on a high stool (hip flexed 90 and abducted 45), and then letting the trunk hang down in forward flexion as far as feels comfortable.

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Motion: The cephalad hand applies postero-anterior pressure to the right side of the sacral base. The caudad hand internally rotates the left hip to inflare and internally rotates the left innominate.

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7) Mobilization for Innominate Outflare Patient Position: Prone Therapist Position: Stands on the left side. The caudad hand contacts the left ankle and the cephalad hand the right side of the sacral base.

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8) Self Mobilization for Innominate Outflare

9) Mobilization for Innominate Inflare Patient Position: Prone with leg externally rotated Therapist Position: Stands on the left side. The cephalad hand contacts the medial aspect of the left ASIS and the caudad hand contacts the area just lateral to the PSIS.

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Motion: The cephalad hand pulls the ASIS laterally and inferiorly while the caudad hand applies medial and superior force to the PSIS.

10) Inferior Glide for Innominate Upslip An upslip is a superior subluxation of the innominate on the sacrum at the SU. The dysfunction is primarily articular with secondary muscle imbalances (as opposed to anterior and posterior innominate rotations, which primarily result from muscle imbalances that secondarily restrict SIJ motion). Signs on the involved side include Superior positioning of the ASIS, PSIS, iliac crest, pubic tubercle, and ischial tuberosity. Inferior Glide of ilium is restricted.

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The patient lies on her back and bends the involved hip to 90. With her hand, she pushes the thigh to the opposite side. 0 A cushion or folded pillow under the foot and lower leg may be necessary to maintain 90 of hip flexion. The stretch is maintained for 2 minutes.

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Patient Position: Prone Therapist Position: Stands to the involved side at the head.

Motion: The outer hand contacts the superior aspect of the iliac crest and applies an inferior and slightly medial force in the plane of the joint.

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A. Distraction in supine Patient Position: Supine with both legs extended Therapist Position: Stands at the foot of the table and grasps the patients ankle on one side just proximal to the malleolus. A belt may be used around the patients trunk, or you may support the opposite foot with your thigh to stabilize the patient.

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11) Distraction for Innominate Upslip Simple longitudinal distraction of one lower limb tends to induce a combined downward and forward movement of the innominate on that side. The signs are the same as in the iliac upslip, except that the innominate is also in anterior rotation so that the PSIS is superior and the ASIS is inferior on the involved side (iliac upslip with an anterior rotation). Distraction may be applied in either supine or prone.

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Motion: Apply a gentle, caudal distraction force through the lower leg until the exact position of the leg that will localize the force to the SIJ is attained. Distraction is then applied by pulling the leg, leaning backward with the trunk, and twisting the pelvis, while pushing against the other (outstretched) leg with the thigh. B. Distraction in prone

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C. Self Distraction in standing

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12) Sacral Nutation Technique This is used to reduce a sacral counternutation positional fault, commonly caused by a postural flat back, or flexed sitting or standing postures and coccygeal muscle spasm. Signs include Lumbar spine hyperflexion Shallow (posterior) sacral sulci Deep (anterior) inferior lateral angles, Less prominent PSIS Sacral flexion restriction L5 to S1 (and possibly generalized) restriction in lumbar extension Patient Position: Prone with pillow under the abdomen and the legs externally rotated Therapist Position: Stands at the level of the pelvis on the involved side, facing the foot of the table

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The patient is instructed to stand with one leg on a stool and hang the affected down over the side with a weight attached (e.g., ankle weights, heavy boot). Traction is applied for 15 to 30 minutes. The patient should be encouraged to move the leg gently through a limited range of motion at the hip to help relax the muscles and stretch out any structures in the hip and pelvic girdle region.

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Motion: The base of the inner hand contacts the sacral base, with the arm directed at a right angle to the base. The mobilizing hand glides the cranial surface of the sacrum ventrally, directing the sacrum into nutation. Incline the pressure toward the patient's feet. 13) Sacral Counternutation Technique This is used for sacral nutation dysfunction, commonly caused by an increase in the lumbosacral angle because of structure or poor abdominal tone combined with lumbar spine hyperextension and a weak gluteus medius and maximus. Signs include Deep (anterior) sacral sulci and shallow (posterior) inferior lateral angles Increased piriformis and psoas tone Sacral flexion hypermobility or sacral extension restriction Possibly tenderness and tightness bilaterally in the tensor fasciae latae Patient Position: Prone with legs internally rotated Therapist Position: To one side of the pelvis, facing the head

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Motion:

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With thenar or ulnar contact of the inner hand on the sacral apex, apply a postero-anterior force on the apex of the sacrum when the sacrum is felt to extend.

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Motion: An inferior, slightly medial force is applied onto the left side of the sacrum by taking up tissue tension on the posterior aspect.

B. Sacral Right Rotation Patient Position: Prone Therapist Position: On the right side of the patient with the ulnar aspect of the right hand on the posterior aspect of the left inferior lateral angle. The left hand contacts over the PSIS of the right ilium.

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A. Sacral Right Side-bending Patient Position: Prone Therapist Position: Stands on the right side of the patient facing the feet. The ulnar aspect of the left hand contacts the posterior aspect of the left side of the sacrum with the fingers pointed toward the feet.

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14) Sacral Right Side-bending Technique for Left-on-Left Sacral Torsion Dysfunction

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Motion: The right hand applies postero-anterior force to the posterior aspect of the left inferior lateral angle, and the left hand applies antero-lateral force to the right ilium for stabilization. C. Self Treatment of Left Sacral Rotation

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15) Pubic Decompression Technique Patient Position: Supine with legs externally rotated. Therapist Position: Stands on one side of the patient facing the patient

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The patient lies supine with the hips and knees flexed. A padded dowel (2/5 cm x 10 cm) is placed vertically on the left side of the sacrum to encompass L5-S 1 and S1-S3. The patient maintains this position for 2 minutes. After treatment, retest mobility.

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Motion: Crossed-armed lateral pressure is applied to the medial aspect of the ASIS with the heels of the hands to decompress. Advantages: Soft tissue inhibition-stretch to the pelvic diaphragm is usually indicated. Encourage movement within pain tolerance to promote pubic motion. 16) Inferior-Superior Pubic Glide Technique Patient Position: Supine Therapist Position: Stands to the side of the patient. The heel of one hand is placed against the ASIS from above on the far side so the direction of movement is caudad on the ASIS. The heel of the opposite hand is placed against the underside of the other ASIS so the direction of movement of this hand is cephalad on the ASIS.

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Motion: The ASIS are moved in the opposite caudad and cephalad directions. More localized accessory movements can be performed directly on the pubic ramus. 17) Inferior-Anterior Pubic Glide Technique Patient Position: Supine Therapist Position: Stands to the side of the patient. The base of the left hand contacts the superior aspect of the pubic ramus on the involved side (left side).

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18) Strain & Counterstrain Correction for Anterior Coccygeal Dysfunction Patient Position: Prone Therapist Position: Stands to the side of the patient. One hand is placed over the sacrum; the opposite hand monitors the tender point on the coccyx.

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Motion: The arm applies a gentle inferior and anterior force to move the pubis down and forward.

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Motion: Place the coccyx in the position of ease by caudally gliding the sacrum. Rotation or lateral flexion of the sacrum, usually toward the tender point side, may be added to fine tune the position. Once the ideal position is achieved, it is held for a period of 90 seconds or so. 19) Postero-Anterior Coccygeal Glide Patient Position: Seated Therapist Position: Stands to the side of the patient. Places the palm of the mobilizing hand over the sacrum and fingers on the coccyx.

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Reference: Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods
by Darlene Hertling & Randpolh M. Kessler (4th Edition)

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Motion: Move the coccyx anterosuperiorly. The mobilization may be easier if the other hand places slight compression on the skull. Alternatively this technique may be performed in supine. Many times just performing the evaluation in sitting will free the coccyx and put it back in place.

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