The Combined Approach

to the Sacroiliac Joint

Claire Middleton-Walker
2007
 Clinical Relevance &
Prevalence of Pelvic
Dysfunction
 Pain
 Pelvic Motion Dysfunction
 Lumbo-Pelvic Dysfunction &
Dysfunction elsewhere
 Pain
Approx 20% of Chronic LBP patients have SIJ
mediated pain (Schwartzer, April, Boduk 1995).
SIJ’s are the source of pain in 15% of LBP and
contribute to a further 23% (Cole et al 1995).
Presence of SIJ symptoms probably more
common in the pregnancy-related and post-
partum LBP population – 49% of women
develop LBP during pregnancy, 50% of whom
present with symptoms consistent with the SIJ
being the source of their symptoms (Ostgaard et
al 1991).
 Pelvic Motion Dysfunction
Pelvic dysfunction was detected in 81% of
patients attending for Rx of LBP, and 12% of
those attending for Rx of other problems
(Cibulka et al 1992).
20% of asymptomatic individuals had positive
findings in 1 or more of the tests (Dreyfuss et al
1990).
24% of the (asymptomatic) subjects had a
positive FFT (Forward Flexion Test) (Egan et al
1996).
 Lumbo-Pelvic Dysfunction and
Dysfunction Elsewhere
Stimulating the SIJ’s, and SIJ joint capsules of
(adolescent) pigs elicits response in multifidus,
glut med, glut max and quad lumb (Indahl et al
1999).
The onset of obliquus internus abdominis,
multifidus and glut max was delayed on the
symptomatic side in subjects with SIJ pain…and
the onset of biceps fem was earlier (Hungerford
et al 2003).
 Anatomy
 Bones
 Nerves
 Ligaments
 Bones
Pelvic ring includes 2 innominate bones and the
sacrum (composed of fused 1st – 3rd sacral
segments).
Innominate bones articulate at the pubic symphysis
and with the spine at the SIJ’s.
Sacrum joins the Lx spine at 1 pseudojoint (L5/S1
disc) and 2 synovial joints (L5/S1 facets).
Cartilage on sacrum = hyaline
Cartilage on ilium = fibrocartilage in appearance
but hyaline histologically
Surfaces are ‘C’ shaped both on sacrum and
ilium.
SIJ is synovial
 Ligaments
SACROTUBEROUS
 Connects ischial tuberosities to the PSIS.

 Some fibres are continuous with fibres of biceps

femoris, hence tight hamstrings can affect this

ligament.
 Neural tissue that supplies the inferomedial buttock

passes through this ligament and can become

tethered in this ‘soft-tissue tunnel’.
 Demonstrates most clearly the functional tension

dynamics of the whole complex (i.e. when its tight

they’re all tight).
 Ligaments Contd.
DORSAL SACROILIAC LIGAMENT
 Is also functionally and clinically significant as
it appears isolated in following a reverse
pattern of tension and slackness.
 Ligaments Contd.
ILIOLUMBAR
 Extends from the transverse processes of L4

& 5 to the iliac crest.

 Stabilising the lumbo-sacral junction, it resists

side glide, rotation and flexion.

 Said to ossify in later life.
 Ligaments Contd.
SACROSPINOUS
 Connects ischial spines to lateral borders of

the sacrum and coccyx, resisting nutation.

 A large proportion of the pelvic floor muscles

attach to this ligament. Thus, SIJ problems

can affect the pelvic floor (manifest in bladder
problems) and vice versa.
 Nerves
SIJ richly innervated by nociceptors that sense
and transmit pain.
The joint capsule contains nerve fibres that
transmit pressure and proprioception.
Innervation of the SIJ is from the posterior
primary rami of L4 through S3 posteriorly, and
the anterior primary rami from L2 through S2
anteriorly.
SIJ capsular stimulation may refer various pain
patterns to the buttock, groin, thigh, calf, or foot.
 Motion
ROM occurs primarily as a “sliding” of one bone
against the other.
ROM approx. 2° of rotation and 2mm of
translation (Sturesson et al 1989 & 2000).
Maintained throughout life but does decrease
with age.
Innominate moves into anterior and posterior
rotation.
Sacrum moves into nutation and
counternutation.
 Motion Contd.
POSTERIOR ROTATION OF ILIUM =
NUTATION OF THE SACRUM
ANTERIOR ROTATION OF THE ILIUM=
COUNTRNUTATION OF THE SACRUM

Nutation = Close pack for SIJ ligaments =

Increased joint stability ☺
Counter-nutation = Loose pack = Decreased
joint stability
 Stability
SIJ is stabilised through a complex modified
friction mechanism. Consequently, stability of
the joint is increased as the joint is compressed.

Force Closure – The Myofascial System

 Compressive forces can be applied by activation of
the muscles.
 Inner = resp and pelvic diaphragms, trans abs,
multifidus and (?) deep fibres of psoas.
 Superficial = glut max, erec sp, biceps fem, lat dorsi.
Form Closure – The Osteoarticularligamentous
System
 Passive components of stability – structures that
passively limit ROM and/or increase the friction
coefficient and the effectiveness of the compressive
forces in limiting shear.
 During adolescence the joint becomes more
convoluted with interlocking ridges and grooves,
which enhances the efficiency in preventing shear.
Sacrotuberous ligament becomes tight if sacrum
nutates and/or innominate posteriorly rotates. As
it tightens, so do most of the other ligaments of
the pelvis.
As tension is increased, the sacrum and
innominate are drawn together, compressed and
stabilised.
Uniquely, the Dorsal SI ligament is put under
tension by opposite positioning of the sacrum
and innominate.
Iliolumbar ligament is tensioned both in nutation
and counternutation.
 Primary SIJ?
Pain usually unilateral, below L5/S1, worse over
and around PSIS.
Lumbar spine NAD on examination.
≥ 3/5 pain provocation tests positive.
Signs of instability
 Active hip flex painful / weak
 Posterior ilial rotation reduces pain
 Pain on coughing, sneezing or mvt is relieved if pelvis
is stabilised
 Sitting slumped may be more comfortable than sitting
upright
 Assessment
ACTIVE SLR: To assess dynamic SIJ stability.
KINETC TESTS: To determine side of
predominating dysfunction (which side to treat
and to re-assess after Rx).
POSITIONAL ASSESSMENT: To determine the
effect of the dysfunction on the positions of the
sacrum and ilia (what to treat).
PASSIVE MOVEMENT TESTS: To determine
whether the dysfunction is articular or myofascial
in nature (and therefore how to treat).
Active SLR test (SIJ stability)
Valuable in 3 ways:- identifies SIJ
instability, identifies ways in which this
may be corrected, provides a valuable
reassessment of the effect of intervention.
Weakness or pain on active SLR may
indicate poor dynamic stability (force
closure) of the SIJ.
If pain/weakness is reduced by strategies,
SIJ has tested positive for instability.
 Performing Instability Test
1. Patient performs SLR
• Patient monitors for pain / weakness
• Therapist monitors for evidence of poor control
2. Therapist assesses effect on pain / weakness
of:
• Increasing Form Closure
• Increasing Force Closure
 Increasing Form Closure
Manual stabilisation of the pelvis
 Gentle manual posterior ilial rotation
Ipsilateral (increases form closure)
Contralateral (decreases form closure)
 Pelvic compression – artificial stabilisation
Bilaterally applied medially directed force just postero-
superior to greater trochanter (increases form closure)
Application of SIJ stabilisation belt
 Just above greater trochanters, across SIJ’s
 Increasing Force Closure
Facilitation of dynamic stabilisers

 Richardson & Snijders 2000

Contraction of trans abs and multifidus → increased stiffness
of SIJ
 Wingerden et al
Contraction of erector spinae, biceps femoris, gluteus
maximus & lat dorsi → increased stiffness of SIJ
 Kinetic Tests
Assess contribution of SIJ motion to the
performance of normal physiological lumbo-
pelvic movements.
Deviations from the ideal/expected movements
noted as patient moves.
Deviations indicate that the SIJ is not moving
appropriately and motion of the SIJ is not being
controlled adequately.
Called a +ve Kinetic Test.
 Kinetic Tests Contd.
Used as reassessment markers for the effect of
treatment to the pelvis.
Kinetic Tests DO NOT provide any information
about the nature of the dysfunction (articular vs.
myofascial, whether treatment should be
directed at the ilium/sacrum/lumbar spine).
DO NOT indicate that the SIJ is stiff.
DOES NOT necessarily indicate that the SIJ
problem is the primary problem.
 “Dominant Eye”
For accuracy and consistency.
Dominant eye placed over midline of the patient
so that its equidistant from the bony landmarks
being assessed.
Always stand on the same side of the patient
during assessment.
Make little window with arms out in front and
look at object.
Close one eye at a time.
 The Tests
Forward flexion in standing (Piedallu’s)/sitting
Hip flexion in standing (Stork/Gillet)
Hip extension in standing
Rotation in standing/sitting
Lateral flexion in standing
 Forward Flexion
Standing (Piedallu’s)
 In standing palpate bilateral PSIS’s
 Observe levels
 Subject flexes forwards
 Abnormal = override of ipsilateral PSIS on
affected side
 Record
Sitting – eliminates muscular tension and
leg length difference
 Hip Flexion in Standing
Movement of the SIJ can be detected by placing
one thumb on the spinous process of S2 and the
other on the PSIS whilst the patient repeatedly
flexes the hip to 90°.
As the hip is flexed the ilium on that side rotates
backward and the respective thumb should drop.
If thumb stays at same level or moves higher
this is a positive test for dysfunction.
Record
 Positional Assessment
Investigates the way in which the presiding
dysfunction has affected the positions of the
ilium and the sacrum.
Indicates which treatment techniques will be
appropriate.
Any asymmetry is considered to be a
malpositioning of the dysfunctional side relative
to the other side.
 Positional Ax of the Ilium
Supine
 Under-surface of the prominence of the ASIS
 Most superior aspect of the iliac crest

Prone
 Inferior surface of the PSIS
 Most superior aspect of the iliac crest
 Most inferior aspect of the ischial tuberosity
 Interpretation
4 possible ilial positional diagnoses:

 Anteriorly rotated (v. common)

 Posteriorly rotated

 Upslip (v.common)

 Downslip (never really happens)

 Positional Ax of the Sacrum
Done by comparing the depth of the sacral base
on the kinetic +ve side to that on the other side –
asymmetry indicates dysfunction.
Assessment of the distance from the posterior
aspect of the PSIS to the sacral base –
symmetrical/shallower/deeper.
Sacral position changes with lumbar position;
therefore perform assessment in a neutral spine
position as well as in full lumbar flexion and
extension.
 Sacral Base Palpation
Start with thumbs symmetrically placed on
posterior aspect of PSIS.
Drop medially off PSIS and sink down until firm
contact made with sacral base.
Assess whether K+ side is symmetrical, deeper
or shallower.
 To palpate…
Locate ILA of sacrum and ischial tuberosity of
ilium. Sacrotuberous ligament runs between
these landmarks.
Palpate at junction of proximal and middle 1/3
with anterolateral / cephalad pressure.
Compare elasticity / tension / tautness.
Sacrotuberous Ligament Palpation
To assess tension and tenderness.
Tension can be altered by position of ilium or
sacrum, and also by changes in the
tension/tone/activity of certain muscles (eg. LHO
biceps femoris, piriformis and erec. spinae).
Often found to be lax on the side of SIJ
instability +/- pain.
Occasionally found to be tender on side of
instability +/- pain.
Positional Ax sacrum – lumbo-sacral flexion
 Sacrum counternutates
 With the patient sitting slouched (sit back and slouch)
on side of the plinth
 Can also assess on the edge of the plinth rolled into a
ball

Positional Ax sacrum – lumbo-sacral neutral

 Prone

Positional Ax sacrum – lumbo-sacral extension

 Sacrum nutates
 Prone lying but propped up onto elbows
 Interpretation
In Lx/Sx F In Lx/Sx In Lx/Sx E Diagnosis
Ø
Deep Deep Deep

Shallow Shallow Shallow

Deep ? Symmetrical

Symmetrical ? Shallow
Passive Movement Assessment
Ilium is moved on stabilised sacrum.
ROM and end-feel are assessed.
Point in range at which sacrum begins to move
with the ilium identifies the end of SIJ range.
Six tests – 2 physiological glides (ilial anterior
and posterior rotation) and 4 accessory glides
(cephalad, caudad, AP and PA of ilium on
sacrum).
Passive movement tests are used to:-
 Assist in the differentiation between articular and
myofascial problems
Myofascial problems have normal joint mobility
Articular problems demonstrate severe
hypomobility
 Identifying “fibrotic” sacroiliac joints
These have moderate joint hypomobility and often
respond best to passive mobilisation techniques.
 Assess the effect of muscle activity on hypermobility
when associated with sacroiliac joint instability
 Performing the Tests
Ilia Posterior Rotation – An antero-superior glide

Ilia Anterior Rotation – An infero-posterior glide

Ilia AP Glide
Ilia Cephalad Glide

Ilia Caudad Glide

Ilia PA Glide
 Interpreting the Results
Assess passive movement in the direction of
resolution.
In MYOFASCIAL dysfunction, there is no
restriction to joint mobility in the direction of
resolution.
In ARTICULAR dysfunction, there is marked
restriction to joint mobility.
 SIJ Pain Provocation Tests
Distraction Test

Thigh Thrust Test

Gaenslens Test

Compression Test

Faber Test
 SIJ Treatment
Treat intra-articular first, then myofascial.
Treatment is followed y re-assessment of kinetic
tests, position and passive mvt tests as
appropriate.
Perform techniques at movement barrier.
MET’s incorporate isometric hold of 7 seconds
followed by a 2-3 second pause before
mobilising – considered to be the time taken for
reciprocal inhibition to occur. The technique is
non-provocative.
All side lying techniques are done with K+ side
uppermost, and positioning begins in hip/knee
90° flexion, trunk neutral.
 Ilial Dysfunction
Ilia – Anterior Rotated
 MYOFASCIAL – MET in supine

 MYOFASCIAL – MET in side lying

 INTRA-ARTICULAR – “Chicago”

 INTRA-ARTICULAR – Mobilisation in side

lying
 Ilial Dysfunction
Anteriorly Rotated Ilia
Assessment:
 Positive kinetic test on the side of dysfunction
Palpation:
 Supine – ASIS inferior (most reliable)
 Prone – ischial tuberosity superior
Treatment:
 Supine
 GENTLE isometric hip extension at movement barrier
 Mobilise via ischial tuberosity (i.e. not into hip flexion)
Reassessment:
 Kinetic test
 Levels of ASIS/PSIS may take time to change
because of myofascial changes
Home Exercise:
 Home MET (knee to chest, resist extension)
 Ilial Dysfunction
Ilia – Posterior Rotated
 MYOFASCIAL – MET in prone

 MYOFASCIAL – MET in side lying

 INTRA-ARTICULAR – Gd V in prone

 INTRA-ARTICULAR – Mobilisation in side lying

 Ilial Dysfunction
Posteriorly Rotated Ilium
Assessment:
 Positive kinetic test on side of dysfunction
Palpation:
 Supine – ASIS superior (most reliable)
 Prone – Ischial tuberosity inferior
Treatment:
 Prone
 GENTLE isometric hip flexion at movement barrier
 Mobilise via PA / Ceph / Lateral on PSIS
Reassessment:
 As previous
Home Exercise:
 Home MET
 Lie prone with hip in extension on pillow
 Push down
 Ilial Dysfunction
Ilia – Upslip
 Leg pull – supine

 Leg pull – Gd V in prone

 Ilial Dysfunction
Inominate Upslip
Assessment:
 +ve kinetic test on side of dysfunction
Palpation:
 Patient supine with pillows under knees
 Prone – PSIS, iliac crest and ischial tuberosity
superior
 Supine – ASIS higher
Treatment:
 Patient supine
 Leg in internal rotation to protect hip
 Find point of maximal resistance to traction – 20° -
40° flexion and 20° abduction
 Alternate traction with isometric hip extension
 Alternate traction with contraction of ipsilateral trunk
lateral flexors
Reassessment
 Ilial Dysfunction
Ilia – Downslip (never happens!)
 Sacral Dysfunction
Sacrum – unable to nutate-restriction to nutation
 MYOFASCIAL – in side lying

 INTRA-ARTICULAR – Gd V in prone

 INTRA-ARTICULAR – “Chicago”
 Sacral Dysfunction
Sacrum – unable to counter-nutate
 MYOFASCIAL – in side lying

 INTRA-ARTICULAR – Gd V in side lying