Sacro-iliac Joint Pain

1st September 2018

Presenters:
Michael Dermansky – Senior Physiotherapist and Managing Director
Nicole Davies – Accredited Exercise Physiologist
Stephen Panagos – Physiotherapist

A: 737 High Street, Kew East, VIC, 3102 T: 03 9857 0644 F: 03 9819 7233 W: mdhealth.com.au E: admin@mdhealth.com.au
 The Sacro-iliac Joint (SIJ)
• Introduction
• SIJ Theory –
• Anatomy & Pathologies
• SIJ Assessment
• Function & Stability testing
• Strength testings
• Other tests to help diagnosis
• Significant Findings & Treatments
• Case Studies
 About MD Health:
• Comprise of Physiotherapists and Exercise Physiologists
• Work with variety of people
• Apparently healthy
• Musculoskeletal pathologies/injuries
• Neurological and Cardiovascular Diseases
• Full Body Assessments > Reassessments
• Individualised treatment plans
• Injury Rehabilitation
• Injury
• Surgery – Pre and Post
• General aches & pains
• Pilates and Strength & Conditioning Training
• Core stability
• Strengthening
• Cardiovascular Assessment/Rehab & High Intensity Interval
Training
 SIJ - Theory
• Anatomy and Kinematics
• Pathophysiology
 The Pelvic Girdle
A region that supports the abdomen and the organs of the lower
pelvis and also provides a dynamic link between the vertebral
column and the lower limbs.
Diane Lee, The Pelvic Girdle – an approach to the examination and treatment of the lumbopelvic-hip region
 SIJ Anatomy Overview
• The SIJ is diathrodial (synovial anterior and fibrous posterior)
• The articulating surfaces of the sacrum are C-shaped and become
grooved in adulthood
• SIJ movements are nutation (superior sacrum tips anteriorly) and
counter-nutation (superior sacrum tips posteriorly), and lesser
amounts of torsion and translation
• Supported by active and passive systems and structures

http://en.wikipedia.org/wiki/Sacroiliac_joint
 SIJ Anatomy Overview
Passive system
The pelvis and Sacro-Iliac Joint (SIJ), with associated ligaments and articular structures,
including long dorsal sacro-iliac ligament and pubic symphysis.

Active system
Major Stabilisers: Glute medius and minimus, multifidus, transverse abdominus and
pelvic floor muscles.
Prime movers: Glute maximus and medius, latissimus dorsi, thoracolumbar fascia, and
lumbar extensors.
 SIJ Anatomy – Pelvic Slings
The co-contraction of muscles and thoraco-lumbar fascia (TLF) across the
Pelvis/SIJ – important for stability.
Posterior Sling
-Ipsilateral Glute Max
-Contralateral Lat Dorsi
-Forces travel across TLF for stability
(Vleeming et al., 2012)

www.igof.in/images/art_pelvic12.jpg
 SIJ Anatomy – Pelvic Slings
Lateral sling Longitudinal Sling
-Unilateral Gluteus medius and minimus -Bilateral erector
spinae
-Tensor fascia latae and iliotibial band
-Contralateral adductors
(Lee, Vleeming & Jones et al., 2011)

www.physio-pedia.com/File:Lateral_Sling_111.png

http://rubyslife.ruby-red.com/wordpress/wp-
content/media/grays-erector-spinae.png
 SIJ Anatomy – Thoraco-Lumbar Fascia (TLF)
4 Layers of TLF
• Anterior Layer -
Quadratus lumborum, Psoas
• Middle Layer -
Transversus Abdominus, Internal Oblique
• Deep Posterior Layer -
Transversus Abdominus, Internal Oblique, Multifidus, Erector
Spinae, Long Dorsal Ligament, Sacrotuberous Ligament
• Superficial Posterior Layer -
Gluteus Maximus, Lat Dorsi, External Oblique
http://www.netterimages.com/images/vpv/
000/000/010/10836-0550x0475.jpg
 SIJ Anatomy – Thoraco-Lumbar Fascia (TLF)
Interesting Pelvis/SIJ facts:
• TLF changes over time depending on force applied, (similar to
trabeculae in bone formation) - thickest in places of largest
forces.
• Long dorsal ligament attaches to lumbar ES and multi via TLF,
and also to hamstring in some people. ??
• Myo-fascial slings are interconnected with ligamentous
system especially in lumbo-sacral area.
• TrA is larger in females (males have higher iliac crests).
• Strain and tension on epidermis has unknown effect on
stability (Rocktape).
• Pelvic girdle belt decreased EMG muscle activation of TrA and
IO in healthy females.
http://www.netterimages.com/images/vpv/
000/000/010/10836-0550x0475.jpg
 Force Closure and Nutation
Force closure is the ability of the muscles (including slings) and
fascia of the pelvic girdle to actively move the ilium posteriorly
on the sacrum.
 in turn winding up the pelvic ligaments
= Nutation
(Vleeming et.al., 2012)
This mechanism works consistently throughout gait and single
leg standing and weightbearing.

https://musculoskeletalkey.com/pelvis-3/
 Force Closure and Nutation
If muscles aren’t strong enough or activating efficiently, this can
lead the ilium to move anteriorly on the sacrum (counter-
nutation).
 stresses the long dorsal ligament over time, and causes
muscle bracing
(Vleeming et al., 2012)

https://clinicalgate.com/pelvis-3/
 SIJ Instability
Joint Stability: “The effective accommodation of the joints to each specific load demand through an
adequately tailored joint compression, as a function of gravity, coordinated muscle and ligament forces, to
produce effective joint reaction forces under changing conditions. Optimal stability is achieved when the
balance between performance (the level of stability) and effort is optimized to economize the use of energy.
Non‐optimal joint stability implicates altered laxity/stiffness values leading to increased joint translations
resulting in a new joint position and/or exaggerated/reduced joint compression, with a disturbed
performance/effort ratio.”
(Vleeming A, Albert H B, van der Helm F C T, Lee D, Ostgaard H C, Stuge B,
Sturesson B)
 SIJ Instability
• Anterior/Superior movement of the innominate on the Sacrum
(Uncontrolled Counter‐nutation).
• Puts direct stretch on the Long Dorsal Ligament (Proprioceptive
function).
• Pain referral pattern in the buttock, down the leg posteriorly and/or
laterally up to the foot (usually no neurological symptoms).
• Can feel like Low Back or Hip Pain (especially in pregnant women).
 SIJ Pathology – Pelvic Girdle Pain
• Sacro‐iliac Joint (SIJ) dysfunction (or a reduction in force closure) – leads to:
• Muscle cramping/bracing – gluteal attachments, erector spinae and quadratus lumborum
• Strain of long dorsal ligament over time
• Or pubic symphysis separation/inflammation (due to shearing forces from instability)
• Common in pregnant women – more likely with unilateral SIJ instability (due to presence of relaxin
hormone, leading to greater joint and ligament laxity around the pelvis)
SIJ Pathology – Osteitis pubis/adductor tendonopathy
• Osteitis pubis is an umbrella term for longstanding exercise‐related groin pain, usually
characterised by pubic symphysis irritation.
• Diagnoses include adductor tendinopathy, iliopsoas dysfunction, abdominal wall
pathologies (e.g. hernias), and pubic bone stress reactions.
• The fundamental aetiology is that mechanical overload
of the pelvic region causes failure of local tissues.
• Usually more than one entity is present.
• Contributing factors may include:
‐ Increased adductor and rectus abdominis tone
‐ Poor lumbopelvic stability
‐ Lx/SIJ dysfunction
‐ Decreased hip ROM
‐ Iliopsoas shortening

http://www.beliefnet.com/healthandh
ealing/images/BK00034_ma.jpg
 SIJ & Biomechanics
• All true trunk/lower limb flexion, extension, & rotation comes from 3 levers
acting on a stable pelvic platform especially in athletic or dynamic
movement (levers = Torso and 2 legs).
• Gait retraining (use of upper limb in walking).
• ASLR and Gillet’s special tests will assess level of force closure (functional
test).
• In exercise prescription and treatment start with short levers first.
 SIJ & Biomechanics
Lifting

Forward Bending or full Nutation of the sacrum Close packed, most stable
extension (Supported by interosseous
and sacrotuburous
ligament)
Returning from bending Contraction of glut max Requires Motor control
and lat dorsi required for (Glut max, lat dorsi), hams
force closure relaxed
 SIJ – Biomechanics in Gait
Ipsilateral Sacral rotation Contralateral Close or Open

Toe-off Anterior Rotation Contra Heel-strike to Mid-stance Posterior Rot, Ipsi Requires Motor control
moving to anterior (Glut max, Lat dorsi),
rotation ( due to hams relaxed
contra rotation of
sacrum)
Swing phase Posterior Rot Ipsi Mid-stance to foot-off Posterior Rot, Contra Requires Motor control
moving to anterior (Glut max, Lat dorsi),
rotation ( due to hams relaxed
contra rotation of
sacrum)
Heel strike Posterior Rot Ipsi Foot-off Posterior Rot, Contra Close packed, most
moving to anterior stable
rotation ( due to
contra rotation of
sacrum)
Heel-strike to Mid- Posterior Rot, moving to Ipsi Toe-off Anterior Rotation Contra Requires Motor control
stance anterior rotation ( due (Glut max, Lat dorsi),
to contra rotation of hams relaxed
sacrum)

Mid-stance to foot-off Posterior Rot, moving to Contra Swing phase Posterior Rot Ipsi Requires Motor control
anterior rotation ( due (Glut max, Lat dorsi),
to contra rotation of hams relaxed
sacrum)

Foot-off Posterior Rot, moving to Contra Heel strike Posterior Rot Ipsi Close packed, most
anterior rotation ( due stable
to contra rotation of
sacrum)
SIJ/Pelvis Assessment
 Gillet’s Test

• Functional test – assesses force closure

during SLS

Thumb placement:
• PSIS
• S2/S3
 Gillet’s Test
• Ax right side with right SLS
• Ax L side with left SLS
What to look for:
• Posterior movement of SIJ – pelvis moves
posterior to sacrum (nutation)
• Anterior movement of SIJ – pelvis moves
anteriorly on sacrum (counter-nutation)
• This tells you whether or not the patient has
adequate force closure, but it doesn’t tell you
why!
 Prone SLR
• Test of order of muscle activation across SIJ
• “Feel” – multifidus, glutes, hamstrings (ideal order)
• Repeat either side
 Active Straight Leg Raise
• Client in supine position
• Client asked to actively SLR (~20-30cm)
• Client to rate difficulty:
• 0 = impossible
• 1 = Extremely difficult
• 2 = Difficult
• 3 = Moderate
• 4 = easy
• Be aware of any hip hitching or lifting of pelvis off
bed.
• Add bilateral compression for intra-articular
component.
• Add sustained compression for 20-30secs to allow
unloading of passive structures (Re-setting neuro).
• Re-assess difficulty
• 5 = Easier
 Active Straight Leg Raise
Dynamic Force Closure (using MMT – more objective)
• Active SLR
• Active SLR – Compression (See previous)
• Active SLR – Sustained compression (See previous)
• Active SLR – TA contraction
• Active SLR – Gluteal contraction
• Active SLR – Lats/TLF Bilateral
• Active SLR – Adductor contraction
• Active SLR – Pelvic Floor facilitation

• Look for strength changes – guides what you focus Example – ASLR with Lat activation
on with exercise (Slings etc.)
 Palpation
Posterior
• Long Dorsal Ligament
• Posterior hip joint
• Glute Medius
• Gluteus Minimus attachment (greater trochanter)
Anterior
• Pubic Symphysis
• Pubic Rami

• Findings may indicate source of pathology.

Glute Medius Palpation in side lying
 Palpation
Long Dorsal Ligament
• Pain provocation
• Must be on the long dorsal ligament
• 5 mm each side is not positive test (glut
attachments, TLF layers, sacrum etc)
• Only requires gentle pressure https://i.ytimg.com/vi/bSF1eahMoFU/hqdefault.jpg
 Addition Pain Provocation Tests
Compression test

• Aim is to stretch the posterior

sacroiliac ligaments and compress
the anterior SIJ.
• Client in supine position.
• Apply pressure is from one iliac
crest to the opposite iliac crest.
• Pain produced may indicate source
of pathology is from SIJ.
 Addition Pain Provocation Tests
Distraction test

• Client in supine.
• Posterior and lateral force is applied to
both anterior superior iliac spines.
• Stretch the anterior sacroiliac ligaments
and synovium.
• Pain produced may indicate source of
pathology is from SIJ.
 Addition Pain Provocation Tests
Thigh Thrust

• Client in supine.
• Hip is flexed to 90° and the knee is bent.
• Apply posterior shearing stress to the SIJ
through the femur.
• Excessive adduction of the hip is avoided,
as combined flexion and adduction is
normally painful.
 Addition Pain Provocation Tests
Squish/AP shear test

• Client in supine.
• Apply posterior force through inferior
aspect of ASIS.
• Note any differences in quality and
quantity in movement.
• Can indicate unilateral stiffness in SIJ.
 Additional Tests – Standing/Sitting Flexion
• Client in standing position
• Palpate both PSIS
• Ask client to flex forward
• Note if one PSIS moves before/further
than the other

• Findings can also be compared with

sitting flexion where test is repeated
with client in sitting position instead
• Testing for Unilateral stiffness OR
instability
 Additional Testing - DRAM
• Diastasis of Rectus Abdominal Muscles
(especially post-natal)
• Assessible via Ultrasound (or assessible by
feel – finger widths – less accurate) –
assess above and below umbilicus
• Supine (crook lie) position – measure at
rest, then in small crunch (concentric
contraction Rec Ab)
• 10mm is normal. >10mm is DRAM – e.g. if
measured at 15mm, there is a 5mm DRAM
SIJ – Significant findings and Treatment

Glute Med trigger point MFR

 SIJ pain - Diagnosis
Underlying cause of SIJ or Pelvic Girdle Pain is SIJ Instability
SIJ instability on Ax:
Gillet’s Test
• Anteriorlising with WB (normally) and/or NWB (unusual, only if very unstable)
• Posteriorlising with hip ext. (not often - stiffness)
Prone Straight leg raise
• Normal activation pattern – Glut with Multifidus, then Hams
• Pathological – Hams first, counter-nutates sacrum
Active SLR
• Effortful or painful
• Eases with TA/Lat/Glute activation
Other findings:
• Palpation of long dorsal lig. Painful
• Muscle bracing – glute med (common)
• Pain provocation tests +ve
 SIJ Pain – Treatment
All SIJ Rx highly dependent on cause of the condition - on which sling has the
largest effect on stability

• Basic stability - TA strength and control

• Dynamic control – most common – post sling (Gluteus max, and lat dorsi)
– Bridging, hip extension
– Hip control
• Activation of gluteal muscles to initiate movement
• Reduce SIJ stiffness, usually on the other side
– SIJ mobilization
• Must take Lumbar pathology into account
– Lx disc bulge work, with extension based pelvic exercises
– Lx facet joint pain, with flexion based pelvic exercises
 SIJ Pain – Acute Treatment
Anything that brings the sacrum into nutation reduces SIJ pain

• Mobilisation into nutation or innominate into posterior rotation

• Full range lumbar flexion or extension
• Hold-relax stretches/Muscle energy techniques of the hamstrings
• To inhibit them from pulling the sacrum into counter-nutation
• Tape across SIJ or into nutation
• Traction in the line of the SIJ also helps reduce stretch on the Long Dorsal
Ligament
Exercises
• Bilateral – co-contraction glute max / multifidus, promotes force closure to
take long dorsal ligament off stretch
Case Studies
MD Health Student Training and Future Events
• Private Facebook Group “MD Health Students”
• (please write down your email that is linked to your FB account, we will send out invites
to attendees):

- To share parts of tutorials and Full Body Assessment

- Answer questions/queries from students – learn off each other!
- Musculoskeletal case studies
- Articles and research
- Advertise upcoming MD Health events
MD Health Student Training and Future Events
Upcoming Student Seminars in 2018 (Dates TBA):
- LBP (Nov)

Opportunities for ongoing training at MD Health:

- For committed students 2-3hrs per week (late 2nd semester, approaching graduation)
- Practice assessment and treatment techniques - tutorials
- Exercise prescription including pilates