Osteopathic Evaluation and

Treatment of Sacroiliac Joint
Problems
Virginia Osteopathic Medical Association
Roanoke, VA
Sept 24-26, 2010
Mark Rogers, D.O., M.A., CAQSM
Associate Professor, Dept Family and Sports Medicine
Virginia College of Osteopathic Medicine
Team Physician, Virginia Tech
Saunora Prom, D.O.
Sports Medicine Fellow
Virginia College of Osteopathic Medicine
Virginia Tech

Objectives
• Review some basic functional
anatomy of sacroiliac joint (SIJ)
• Review some common physical
exam maneuvers to identify SIJ
dysfunction
• Discuss indications and
contraindications for osteopathic
manipulation (OMM) of SI pain
• Demonstrate skills to perform
various common OMM
http://marketing.blogs.ie.edu/archives/mdac%20Objectives.jpg

Resources
• Foundations for Osteopathic Medicine,
2nd edition
• Outline of Osteopathic Manipulative
Procedures—The Kimberly Manual; Paul
Kimberly
– Chapter 10 – Pelvis
• Principles of Manual Sports Medicine;
Steven Karageanes
– Chapter 21 – Lumbosacral Spine
– Chapter 22 – Hip and Pelvis

Anyone can find disease.jpg .” --Dr.cartoonstock. 1874 http://www. A. Still.• “To find health should be the object of the doctor.com/lowres/lka0128l.T.

Incidence • 85 % of the general population will have low back pain(LBP) – Most common reason to see a physician for musculoskeletal condition – Second most common pain complaint – 35% of adolescent athletes – 27 % LBP in adults is MS strains • Overuse injuries are prone to recurrence – 26% males/33% females • Risk regardless of sex. . Mayer. age. occupation. 22:1132–6. Curr Sports Med Rep 2010.16(1):37–46. 9(1):60—66. • Medical Expenditure Panel Survey (MEPS) – Costs inc 65% from 1997-2005 to $86 billion – Ave cost of single work related back injury is over $8000 – Adults with functional limitations inc by 19% Curr Opin Pediatr 2004. etc. Spine 1997. S.

SL. 9: 61-8 Zelle. Pain Physician 2006. BS. 85: 997-1006 . BA. et al. Clin J Pain 2005. 21: 446-455 Foley. Am J Phys Med & Rehab 2006. et al. et al.Anatomic Relationships & Low Back Pain • The SI joint – Up to 30% of LBP • Up to 80% during pregnancy – L shaped articulation • 1-2mm wide – Both diarthrodial & synovial joint • Hyaline cartilage • Fibrocartilage – Significant variability – Adaptive changes third decade • Gravitational stress • Increased size & # of ridges • Thickened capsule • Accessory articulations Forst.

BS. 21: 446-455 Foley. Clin J Pain 2005. Am J Phys Med & Rehab 2006. et al. 85: 997-1006 . et al. BA.Functional Anatomy • Region serves as a force transfer link between the torso and lower extremities • Stability/Instability dependent on: – Muscular – Neural – Ligamentous relationships • Breakdown and degeneration can lead to chronic pain syndromes Zelle.

RE JAOA 1973. 72: 130-137 . pelvic side shift.Functional Anatomy • Hamstrings – Integral role in intrinsic lumbosacral spine stability • Iliopsoas – Eccentrically and dynamically stabilize hip extension and IR – Dysfunction leads to upper lumbars in flexion. innominant dysfunction and gluteus inhibition • Adductors – Eccentrically stabilize upper body via tension on the pelvis during stance phase – Dysfunction can result in pubic shears Kappler.

Functional Anatomy • Parallel. flat joint surface • Self-locking • Form Closure – surface contact • Force Closure – Ligaments – Muscles & Fascia • Thoracolumbar fascia – Load transfer between lat’s & opposite glutes .

Functional Anatomy—Form Closure • The anatomy of the individual joint and the demands of gravity placed on it. define the FORM CLOSURE of a particular joint – “Keystone” • The SI joint becomes stable in part based on its structural orientation FORM CLOSURE of the sacroiliac joint .

Functional Anatomy—Force Closure • Compressive forces & congruency between two surfaces of a joint provide the friction to enhance stability – (i) Segmental Stiffness – (ii) Compression Force Closure (low threshold & high threshold systems) – (iii) Positional Force Closure – (iv) Torsion Control (low threshold & high threshold systems) .

" .“What we are trying to express through the Integrated Model of Function is that there are many components to consider in a functional model and each must be addressed for recovery to be long standing.Diane Lee .

et al. 21: 446-455 Foley. Am J Phys Med & Rehab 2006. et al. BS. 85: 997-1006 . 9: 61-8 Zelle. et al. Pain Physician 2006. BA. Clin J Pain 2005.Clinical Considerations • Differential Diagnoses • Mechanisms – Trauma (up to 58% of time) • MVC • Fall on sacrum • Step into hole – Mechanical causes – Degenerative disease – Laxity • Physical Findings: – Aggravated by • Transitional activities • Activities that require asymmetrical loading through LE or pelvis – Fortin Finger Test – Point tenderness – – – – – – Inflammatory Infection Metabolic Degenerative Malignancy Referred pain • Treatment – – – – – OMM Pelvic stabilization exercises Muscle control/ balancing SIJ belts Injections Forst. SL.

Functional Biomechanical Exam Postural Exam • Approximate foot position • Evaluate both A-P and Lateral curves • Examine foot. and hip alignment . knee.

Functional Biomechanical Exam Tests of Pelvic Dysfunction • Tests functioning of pelvis • Standing / Seated Flexion Test – (+) Standing FT (StFT) = iliosacral dysfunction • Address Pelvis first – (+) Seated FT (SeFT) = sacroiliac dysfunction • Address Sacrum first – (-) StFT / SeFT = either no dysfunction or bilateral lesion (extremely rare) .

americanpainspecialists.com/images/361_leglengthinequality. 104 (10): 411-421 http://www. JAOA 2004.jpg . either primarily or from a dysfunction elsewhere Juhl.Structure and Function • The structure of the pelvis and lower extremities (LEs) directly affects performance • The most common structural challenge for the pelvis when it is to function as a static base is a shorter or longer lower extremity – Anatomically short or long leg – Torsion of the lower extremity – Twisting or rotation of the pelvis in any of the 3 planes. JH et al.

Osteopathic Phases • Right heel strike – Right innominate rotates posterior – Left rotates anterior – Anterior sacrum rotates left – Superior sacrum level – Spine rotates left • Midstance – – – – Right leg straight Innominate rotates anteriorly Sacrum rotated right. 2:47-56 Kuchera.. 2003 . SB right – Rotary @ pubic symphysis Brolinson PG.Gait Cycle…. 2nd edition. M. Curr Sports Med Rep 2003. Foundations for Osteopathic Medicine. SB left Lumbar spine rotated left.

Physical Exam Maneuvers • Hibb’s Test – Pt prone – flex knee to 90 degrees – Internally & externally rotate hip while monitoring pelvis – Pain early probably from hip. later is more likely SI – Can use monitoring hand to confirm engagement of SI joint • Patrick’s / Fabere test – Pt supine – flex & externally rotate hip while stabilizing pelvis – Pain early probably from hip. later is more likely SI .

then SI – If pain occurs as LS movement is detected. or hip – Can use progressively less extension & monitor each joint as to when pain starts in order to further localize . then LS • Yeoman’s test – Pt prone – Extend hip (with or without bent knee) while applying load at L-S joint – Reproduction of pain could be LS. SI.Physical Exam Maneuvers • Goldthwaite’s Test – Palpation technique – Place cephalad palm underneath the LS spine and perform a SLR w/ caudad hand – If pain occurs before LS movement is detected.

Physical Exam Manuevers •Leg lengths •Hibbs Test •FABERE/Patrick’s Test •Goldthwaite’s Test •Yeoman’s Test .

Lower Crossed Syndrome • Muscle imbalances alter movement patterns and add stress to joints – Hypertonic muscles a T-L junction – Lumbar hyperlordosis – Anterior pelvis tilt – External rotation leg .

“Dead-Butt Syndrome” • AKA “Six-pack Syndrome” • Combination of: – Poor muscle activation – Hypertonic iliopsoas – Tight anterior hip capsule – Inhibited gluteus* • Can present with muscle imbalances. recurrent lower extremity muscle problems . low back pain.

“Dead-Butt Syndrome” • Test hip extension firing pattern – 1) Hamstring – 2) Gluteus – 3) Contralateral Quadratus Lumborum – 4) Ipsilateral Quadratus Lumborum 4 3 2 1 Figure 1 .

then curl the crunch • Count out loud to 3 • Don’t release the contraction until back flat on surface • Don’t need to do >25 Position leg as shown & contract gluteus maximus Maintaining gluteal contraction and keeping toes on table.“Dead-Butt Syndrome” • Treatment in the following order: • Address any tight anterior hip capsule component • Stretch iliopsoas • Retrain gluteus to fire • Correct crunch technique • Isometrically contract abdominals first. extend knee Extend toes toward wall .

relax gluteus muscles • After retraining the gluteus. work on timing of contraction. and then strength. continue to work on Core strength too Position leg as shown & contract gluteus maximus Maintaining gluteal contraction and keeping toes on table. extend knee Extend toes toward wall Picture 12  3 stages for gluteal retraining: After retraining the gluteus just to contract voluntarily. .“Dead-Butt Syndrome” • Gluteus muscle retraining – Prone position bring toes up on table – Straighten knee – Tighten gluteus muscles – Maintaining gluteus contraction. extend leg – Extend toes and hold for 3-5 secs – Then slowly return leg to table – LAST.

“Dead-Butt Syndrome” Diagnosis 4 3 2 1 Figure 1 Treatment .

Contraindications for OMT – ↓ sympathetic or ↑ parasympathetic tone would be harmful – Manipulation of the involved structure would be harmful (acutely postop or post-injury) – Vascular supply tenuous – Patient tolerance / Other common-sense situations .

Anterior Innominate Rotations • Pull of musculature is such that one hemipelvis is rotated anteriorly and is resistant to posterior motion. especially rotation • Usually due to tight hip flexors ipsilaterally • Findings: – ASIS is inferior & PSIS is superior on ipsilateral side. but rami are symmetric – (+) StFT. (-) SeFT on ipsilateral side .

Anterior Innominate Rotations .

Pubes stable. – Recheck! .Anterior Innominate Rotations • Dx .(+) StFT on same side as Ant/Inf ASIS. (-) SeFT. – Pt then extends hip isometrically with 3-5# of force for 5-7 seconds. – Relax for 1 second – Take up the newly created ‘slack’ to flexion and repeat. • Tx – Pt supine with ipsilateral knee & hip flexed as far as comfortable. Sup/Ant PSIS.

but rami are symmetric – (+) StFT.Posterior Innominate Rotations • Pull of musculature is such that one hemipelvis is rotated posteriorly and is resistant to anterior motion. especially rotation • Usually due to hypertonic hip extensors ipsilaterally • Findings: – ASIS is superior & PSIS is inferior on ipsilateral side. (-) SeFT on ipsilateral side .

Post/Inf PSIS. • Tx – – Pt supine w/ ipsil. – Recheck . leg hanging off table and hip extended as far as comfortable. – Relax for 1 second – Take up the newly created ‘slack’ to extension and repeat.Posterior Innominate Rotations • Dx . – Pt then flexes hip isometrically with 3-5# of force for 5-7 seconds.(+) StFT on same side as Sup/Post ASIS. (-) SeFT. Pubes stable.

(-) SeFT on ipsilateral side .Inferior Pubic Shears • Pull of musculature is such that one hemipelvis is rotated anteriorly and is resistant to posterior motion • Usually due to tight hip flexors ipsilaterally prior to an injury • Often recalcitrant to OMT d/t improper Dx • Findings: – ASIS is inferior. and pubic ramus is inferior on ipsilateral side. – (+) StFT. PSIS is superior.

Inferior Pubic Shears .

(-) SeFT on ipsilateral side . PSIS is inferior. – (+) StFT.Superior Pubic Shears • Pull of musculature is such that one hemipelvis is rotated posteriorly and is resistant to anterior motion • Usually due to tight hip extensors ipsilaterally • Often recalcitrant to OMT d/t improper Dx • Findings: – ASIS is superior. and pubic ramus is superior on ipsilateral side.

Superior Pubic Shears .

(+) StFT on affected side with uneven pubic rami (sup/ant or inf/post) • Tx .Superior and Inferior Pubic Shears • Dx . May be repeated if needed .Symphysis spread technique: – Pt is supine with bent knees adducted and hips ext flexed – Isometric abduction contraction of 5-10# of pressure is maintained for 5-7 seconds – Proceed to part two.

(+) StFT on affected side with uneven pubic rami (sup/ant or inf/post) • Tx .Superior and Inferior Pubic Shears • Dx .Symphysis spread technique: – Pt is supine with bent knees abducted and hips flexed and ext rotated – Isometric contraction of 3-5# of pressure is maintained for 5-7 seconds – Recheck and repeat as needed .

Innominate Dysfunctions • Standing/Seated Flexion Test •ASIS/PSIS/Pubes/IT • Anterior • Posterior • Pubic Shears .

but rami & PSIS are symmetric – Umbilicus-ASIS distance is shorter on ipsilateral side – (+) StFT. (-) SeFT on ipsilateral side .Inflared Innominate • Pull of musculature is such that one hemipelvis is rotated medially & is resistant to lateral motion • Findings: – ASIS is medial on ipsilateral side.

Repeat as needed – Return to neutral position and recheck .Inflared Innominate • Dx .(+) StFT on affected side with ASIS closer to umbilicus/midline • Tx – Specific muscle energy – Flex & abduct knee & hip while stabilizing unaffected side at ASIS – Have patient adduct hip against isometric resistance of 3-5# for 5-7 seconds – Take up slack to new barrier.

but rami & PSIS are symmetric – Umbilicus-ASIS distance is longer on ipsilateral side – (+) StFT. (-) SeFT on ipsilateral side .Outflared Innominate • Pull of musculature is such that one hemipelvis is rotated laterally & is resistant to medial motion • Findings: – ASIS is lateral on ipsilateral side.

(+) StFT on affected side with ASIS farther away from umbilicus/midline • Tx – Specific muscle energy – Flex & adduct knee & hip while stabilizing unaffected side at ASIS – Have patient abduct hip against isometric resistance of 3-5# for 5-7 seconds – Take up slack to new barrier – Repeat as needed – Return to neutral position and recheck .Outflared Innominate • Dx .

etc. PSIS.Upslipped Innominates • Probably the 2nd most rare of the pelvis dysfunctions we’ll review • Usually due to an axial load up leg into pelvis – front impact MVA with foot on brake. & symphysis are all superior on ipsilateral side – (+) StFT. stepping off unanticipated curb or into a pothole. (-) SeFT on ipsilateral side . • Entire hemipelvis has slid superiorly compared with non-affected hemipelvis • Findings: – ASIS.

Upslipped Innominate • Dx . Maintain moderate traction while supporting unaffected side – Pt deeply inhales/exhales a few times – Return to neutral position and recheck . and pubic rami superior • Tx – – Pt supine & doctor holding affected side just proximal to the malleoli – Slightly abducting the thigh until it’s ‘loose’.(+) StFT on affected side with all ASIS. then test internal rotation until tension reached. PSIS.

& symphysis are all inferior on ipsilateral side – (+) StFT. PSIS. etc. (-) SeFT on ipsilateral side .Downslipped Innominates • Probably the most rare of the pelvis dysfunctions we’ll review • Usually due to a traction force on the leg (bungee jumping.) • Entire hemipelvis has slid inferiorly compared with non-affected hemipelvis • Findings: – ASIS. foot caught in stirrups as patient falls off horse.

and pubic rami inferior • Tx – – With patient lying on unaffected side and knees bent.(+) StFT on affected side with all ASIS. PSIS.Downslipped Innominate • Dx . apply an upward & lateral force on the ischial tuberosity & the ilium – Have patient take several deep breaths while you resist. & then advance cephalad as able & repeat – Return to neutral position and recheck .

Innominate Dysfunctions
• Inflared

• Outflared

• Upslipped

• Downslipped

Strain Counterstrain Procedure



Structural exam
Find tenderpoint
Establish the pain scale for the patient
Passively position the patient into a position of
ease, where the relative tenderness ilicited by
palpation of the same point decreases by 70%
• Hold the patient in this position for 90 seconds
while continuously monitoring the point.
• Slowly, passively, return the patient to the
original starting position.
• Retest the point.

Iliacus Tenderpoint
• The tender point lies 2
to 3 cm caudal to the
point halfway between
the ASIS and the
midline, deep on the
side of the dysfunction

and side bending) .Iliacus Tenderpoint Position of Ease • The patient's hips are markedly flexed and externally rotated bilaterally (ankles are crossed with knees out to the sides) – “Good over Evil” • Fine-tune through small arcs of motion (hip flexion. external rotation.

Piriformis Tender Point • The tender point lies anywhere in the piriformis muscle • Classically 7 to 10 cm medial to and slightly cephalad to the greater trochanter on the side of the dysfunction .

Piriformis Tenderpoint Position of Ease • The patient's leg on the side of the tender point hangs off the edge of the table. the hip is flexed approximately 135 degrees and markedly abducted and externally rotated • Alternative position: patient lateral recumbent .

Strain Counterstrain • Iliacus Tenderpoint • Piriformis Tenderpoint .

(+/-) Sciatic Sx. • Tx: (Muscle Energy) • Pt supine & LE flexed to 90º.Piriformis Dysfunction • Dx . then taken to end-ROM in external rotation • Isometric contraction toward internal rotation with 3-5# of pressure is maintained for 5-7 seconds.(+) TTP over piriformis & (+) SeFT on affected side. Relax for 1 second • Take up the newly created ‘slack’ to external rotation & repeat as needed and recheck .

Sacral Diagnosis for FPR • Patient prone • Place heels of both hands inferior to the ILAs • Direct a cephalad force through the ILAs • Compare sides of the sacrum for freedom/restriction • Restricted side is dysfunctional .

and rest of hand on sacrum • Abduct thigh until motion is felt at SI (to gap the joint) • Gently push leg down toward floor until motion is again felt • Pt takes a deep breath and exhales slowly while physician pushes cephalad against ILA • Release and reevaluate • Retreat as needed if still restricted .Sacral Treatment with FPR • Pt prone with a pillow under abdomen (flatten curve) • Monitor affected SI joint with finger.

• FPR for Sacrum • Piriformis Muscle Energy .

Lateral Recumbent Technique (Long-Lever) • Dx: L3NSRRL – – – – – Pt on Rt side /Lt side up Palpate between SP’s of L3 & L4 & pt’s knees & hips until L3 is in a neutral position relative to L4 Drop pt’s Lt leg over side of table cephalad to the right leg. but foot must not touch the floor While continuing to palpate L3. physician places cephalad elbow in pt’s axilla Places caudad forearm along a line between pt's left PSIS & greater trochanter .

and during exhalation.Lateral Recumbent Technique (Long-Lever) • Dx: L3NSLRR – – – – – Pts trunk stabilized with physician’s cephalad elbow in pt’s axilla Pt's pelvis is rotated anteriorly into the restrictive barrier Pt inhales & exhales. take up further rotational slack Deliver an rotational and gapping impulse thrust with caudad forearm directed at right angles to pt's spine (rotation) while simultaneously moving the pelvis & sacrum caudad to impart Rt SB & Lt rotation Recheck .

Lateral Recumbent Technique (Alternate Long-Lever) • “Kick Start” – – • You may also use the knee as a long lever to help amplify your force – do so cautiously Everything is as previously. but instead of inducing rotation with caudad hand. you ‘kick-start’ the rotation with the knee “Straddle” – – If using the knee is problematic or patient is larger than physician. can also ‘straddle’ leg – do so cautiously Still monitor motion with caudad hand .

HVLA/LVHA Lumbar Spine .

Summary • Low Back Pain is a common problem – SIJ pain up to 30% • Stability/Instability dependent on: – Muscular/Neural/Ligamentous relationships • Structural exam – Postural – Leg length – Somatic dysfunction • Functional Exam – Muscle imbalance • Treatment multifactorial .