“Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things: to help, or at least to do no harm.”
-Hippocrates ( Father of Medicine)
The development of bipedal plantigrade progression is a purely human accomplishment. We share two-legged locomotion with some flightless birds, such as the ostrich, and an arched plantigrade foot with the bear. I sometimes think that we have also retained other characteristics of these animals, namely our ability to bury our heads in the sand and, too often, to act in a “bearish” manner toward our fellow men. However, the orthograde position is exclusively human and permits us, literally, to view the world in an upright manner, although not always acting in an upright way. Perhaps I should apologize for these asides, but I do wish to emphasize the unique character of human locomotion within the animal kingdom. It is this bipedal orthograde position primarily responsible for the mechanical Low back pain in humans.
Low back Pain Interestingly, before 1934 was attributed to dysfunction of the SIJ. In 1934 following a publication by Mixter and Barr about disc herniation leading to Low back pain with radiation to lower limb there was a sudden paradigm shift from SIJ to Disc. All most all LBP were attributed to be of disc involvement thereafter. The researches in past few decades have shown that nociception from SIJ is the source of discomfort in a significant percentage of patients with low back pain( Bernard B, Cassidy JD.1991; Hodge JC, Bessette MD.1999; Schwarzer AC, April CN, Bogduk N. 1995). In this article the details of the Sacroiliac Joint Dysfunctions are described.
Anatomy and Biomechanics of Sacroiliac Joint ( Fig.1, Fig.2)
The sacroiliac (SI) joint is the largest axial joint in the body, with an average surface area of 17.5 cm2 (Bernard TN, Cassidy JD;1991). The adult SIJ is an auricular C-shaped joint. The anterior sacral side of the joint is lined by thick hyaline cartilage, whereas the posterior iliac side of the joint is lined by fibrocartilage( Zelle Boris, 2005). The SIJ has been described as an atypical synovial joint (sacrum is coverd with hyaline cartilage and ilium is covered with fibrocartilage in contrast to typical synovial joint where both the articulating surfaces are covered with hyaline cartilage).
Based on mapping studies, Weisl (1995) described the sacroiliac joints as a twin condyle (bicondylar) joint. As with all bicondylar joints, the two sacroiliac joints behave as two structural but only one functional joint (Barnett et al. 1961; MacConaill & Basmajian 1977). Bicondylar joints have only two degrees of freedom. Pure rotation is impossible (MacConaill & Basmajian 1977). The SIJ undergo small amount of anteroposterior rotatory movement ( Weisl,1955; Sturesson et al, 1989) which appears to range from 20(Egund et al , 1978) to 120 ( Lavignolle et al,1983). The two structurally separate sacroiliac joints create just one functional bicondylar joint. The two separate sacroiliac joints function as one joint, interdependent on each other and never independent of each other (Pitkin & Pheasant 1936; Cibulka et al. 1988; Sturesson et al. 1989).
The SI joints are designed primarily for stability. Their functions include the transmission and dissipation of truncal loads to the lower extremities, limiting x-axis rotation, and facilitating parturition. Compared to the lumbar spine, the SI joints can withstand a medially directed force 6 times greater but only half the torsion and 1/20th of the axial compression load (Dreyfuss P, Dreyer SJ, Cole A et al,2004). These last 2 motions may preferentially strain and injure the weaker anterior joint capsule (Dreyfuss P, Cole AJ, Pauza K.,1995). In a cadaver study, Brunner et al. (1991) found that the main motion in male specimens tended to be translation, whereas in female specimens it was rotational. The maximum range of motion in this study was 1.2 degrees in men and 2.8 degrees in women.
The SI joint is also supported by a network of muscles that help to deliver regional muscular forces to the pelvic bones. Some of these muscles, such as the gluteus maximus, piriformis and biceps femoris, are functionally connected to SI joint ligaments, so their actions can affect joint mobility. The potential for vertical shearing is present in approximately 30% of SI joints, owing to the more acute angulation of the short, horizontal articular component (Mitchell FL 1995).
Neurology of SIJ
The posterior joint receives innervation from L3–S3, and the anterior joint receives innervation from L2– S2 ( Solomon KA, 1957). Nerve innervation to the posterior ligaments arises from the lateral branches of the posterior primary rami L4–S1 and anterior rami L2–S2. Because there are various levels of innervation, pain from the SIJ may present in a varied pattern.
The Sacroiliac Joint is a major contributor of Low back pain. A research study by Sakamoto et al(1999) showed that 26 of the 29 units they identified were nociceptors. In another research study of Sakamoto and Yamashita et al (2001) 29 mechanosensitive units were identified in the sacroiliac joint. Of these, 28 units were classified as nociceptors and 1 unit as proprioceptor. Thus, most of the mechanoreceptors identified in the sacroiliac joints were thought to be nociceptors. These results indicate that the sacroiliac joint is one of the major contributor of lower back pain.
Several studies by Minaki Y and Yamashita ( 1996, 1990 and 1993) found that proportions of nociceptive units were found to be 36% in the lumbar facet joint and 100% in the anterior portion of the lumbar intervertebral disc. The study showed that the proportion of nociceptive units in the sacroiliac joint is 97%. The average mechanical thresholds of the units were 6 g in the lumbar facet joint units and 241 g in the anterior lumbar disc units. In this study, the average mechanical threshold in the sacroiliac joint was 70 g. On the basis of these results, the sensitivity of the sacroiliac joint to pain may be lower than that of the lumbar facet joint and higher than that of the anterior portion of the lumbar intervertebral disc.
CLINICAL PRESENTATION OF SIJ INVOLVEMENT (Fig.3)
Pain from the SIJ is located primarily over the joint ( Inferior sacral sulcus).Pain is felt around/near the sacral sulcus, Gluteal pain near or surrounding the posterior superior iliac spine and pain with palpation of the sacral sulcus (Mennell 1960; Stoddard 1969; Wells 1986; Bourdillon & Day 1987; vander wurff et al 2006).
Due to the multisegmental innervation of the SIJ, pain arising from the SIJ may refer to various anatomic regions and diverse pain patterns have been described. Dreyfuss et al (1996) documented the pain referral pattern in 45 patients with low back pain with a positive response to a diagnostic SIJ block as well as the pain referral pattern in 40 patients with low back pain with a negative response to a diagnostic SIJ block. These authors reported that both patient populations described various and broad patterns of referred pain that encompassed the buttocks, the groin, and the entire lower limb. However, Dreyfuss et al noted that pain referral above the L5 level was not found in patients with pain originating from the SIJ and suggested this finding as a possibly discriminating feature.
In a study by Fortin et al(1994), the SIJ of asymptomatic volunteers were subjected to stress by fluoroscopy-guided joint injections. Although various pain patterns were found, these authors established a composite drawing and identified an area extending 10 cm caudally and 3 cm laterally from the posterior superior iliac spine common to every volunteer. Based on these results, Fortin et al performed a consecutive study in which they identified 16 patients with low back pain with a pain referral pattern consistent with SIJ pain( Fortin, Aprill,1994). Each of these patients had a provocative positive fluoroscopy-guided injection of the SIJ. To conclude the pain arising from the SIJ may radiate into various anatomic regions including the buttocks, the groin, and the entire lower limb. If the pain is referred above the fifth lumbar level, it is unlikely that the SIJ is the source of pain. In patients with SIJ dysfunction, it can be expected that the pain referral pattern includes an area extending 10 cm caudally and 3 cm laterally from the posterior superior iliac spine.
The pain becomes worse and sharp whilst doing activities such as sitting, standing up from a seated position, standing, walking or running. The pain aggravates whenever there is weight bearing on the SI joint. The pain is felt at the ipsilateral side of the sacroiliac joint involvement. The patient frequently changes the body posture to avoid prolonged stress on the SIJ and ligaments. The patient may experience pain during sexual intercourse and also may have difficulty turning over in the bed. No pain with springing of the lumbar vertebrae using a posterior/anterior pressure, but may have pain springing the sacrum or compression of the sacroiliac joints (Mennell 1960; Stoddard 1969).
CLINICAL TESTS FOR SIJ INVOLVEMENT
There are several tests for identifying the SIJ involvement. The Gaenslen test, FABER test, and the POSH test are the most reliable examination techniques with an acceptable clinical reliability of greater than 80% (Dreyfuss P(1996), Laslett M(1994).
Herzog (1989) and Wiles (1980) found the Gillet Test to be reliable with agreement % of 79 and 64 respectively. Bernard (1994) and Lee (1998) have also recommended and accepted the Gillet Test as a reliable test.
FABER Test ( Fig.4)
FABER test (Flexion Abduction External Rotation) is a test for differentiating the Sacroiliac joint involvement from the hip involvement.
Subject’s position:- The subject is in supine lying position.
Therapist’s Position:- The therapist/ clinician stands at the side of the couch.
1. The therapist/ clinician places the foot of the tested side on the opposite knee(figure-4 position).
2. The therapist/ clinician press down gently but firmly on the flexed knee with posterior and lateral force. At the same time the opposite anterior superior iliac spine is stabilised.
Pain in the sacroiliac area indicates a problem with the sacroiliac joints.
Pain in the groin area indicates a problem with the hip and not the spine.
Gaenslen’s Test ( Fig. 5)
Subject’s position:- The subject is in supine position.
Therapist’s Position:- The therapist/ clinician stands at the side of couch.
1. The subject is asked to stand at the edge of the couch, grasp one knee(non-testing side) and bring it to the chest.
2. With the subject in this position the tested side lower extremity is taken for extension, with the therapist/ clinician applying pressure from the knee. At the same time the flexed knee is taken towards the patient’s chest by the therapist.
1.This test causes extreme rotational stress within the pelvis in general and especially within the sacroiliac joint. This is the classical test for confirming or ruling out sacroiliac joint lesion.
2.The pain in the sacroiliac joint on the side of the extended leg indicates a sacroiliac joint lesion.
3.The pain may also be felt at the hip joint if lesion is present. Locating the area of pain will help determine whether the problem is at the sacroiliac joint or the hip joint.
The same test can also be performed with the subject in side lying position.
Posterior Shear Test (POSH) or Thigh thrust test (Fig. 6)
Subject’s position:- The subject is in supine lying position.
Therapist’s Position:- The therapist/ clinician stands at the side of the couch.
1. The therapist/ clinician passively flex the hip of the subject to 900.
2. The therapist/ clinician adducts the hip to the midline for about 300.
3. The therapist/ clinician applies axial pressure along the femur directed antero-posterior.
This maneuver causes posterior shear forces on the ilium and therefore results in pain over the SIJ in symptomatic patients.
GILLET TEST (Fig. 7):-
Subjects Position:- The subject is in standing position.
Clinician/ Therapist Position:- The clinician sits behind the subject.
- The therapist places one thumb over the PSIS and the other thumb at S2 spinous process.
- The subject is asked to perform hip flexion.
For a normal individual during flexion the innominate moves for posterior rotation and the clinician’s thumb (placed on PSIS) moves caudally for 1.5-2.5 centimeters. Instead of moving caudally if it tend to move upwards then the test is positive.
A positive Gillet test signifies mechanical involvement of the pelvic complex in the tested side.
MANUAL THERAPY TREATMENT FOR SIJ DYSFUNCTION
1.UP – SLIP INNOMINATE DYSFUNCTION MANAGEMENT
A.Tug pull manipulation(Fig. 8)
Subjects Position:- The subject is in supine lying position.
Therapist / Clinician’s position:- The therapist stands at the lower end of the couch.
Procedure: – The therapist does the tug pull grasp (the thumb placed in the third web space of the other hand above the ankle and pulls it caudally once barrier is felt The thrust is applied for 3-5 times.
- The tug pull grasp is used in order to prevent unusual hair pulling and irritation in the leg.
- As the knee is in close pack position the force transfers directing to the innominate and the innominate comes down.
Subject position:- The subject is in crook lying position.
Clinicians Position:– The clinician stands at the lateral aspect of the affected side superior to the affected side innominate.
Procedure: – Superior to inferior translation movements (Maitland’s grade IV) are applied with the first web space for 2-3 minutes.
C.MET Technique( Fig. 10)
Subject’s position:-The subject is in side lying position.
Clinician’s/Therapist’s position:-The therapist stands at the side of the couch facing the anterior aspect of the subject.
- The therapist places the palm over the iliac crest with reinforcement of the other hand. The innominate is pulled down till the barrier is belt.
- Once the barrier is palpated the subject is asked to pull the innominate up wards against the resistance (muscular effort is 1/3 rd of the maximal effort)
- The subject is asked to relax and the innominate is pulled down further. The sequence is repeated 3-5 times.
3.ANTERIOR ROTATION OF INNOMINATE DYSFUNCTION
A. Side Lying mobilisation and manipulation Technique (Fig. 11)
Subject’s Position : The subject is inSide- lying position.
Subject’s Position:- The therapist stands behind the subject.
- The therapist places his/her knee to stabilize the sacrum of the subject. In order to place the knee at correct level a pillow is kept just behind the sacrum of the subject (Fig.).
- The therapist flexes the hip of the subject till 110°, adducts the hip and applies ant posterior translation mobilization (Grade IV movements) for 3-4 minutes.
As the hip is taken for 110° of flexion the neutral position of the innominate is achieved due to the pulling of the gluteals. This corrects the anterior rotation component of innominate.
B. Chicago Technique(Fig. 12)
Subject’s Position:- The subject is in supine lying position
Therapist/Clinician Position:- The clinician stands at opposite side of involvement
- The lower extremities are crossed, the affected side lower extremity is kept above.
- The subject is asked to hold the opposite shoulders.
- The therapist passively creates convexity at the side of involvement.
- The therapist places one hand inferior to the ASIS of the involved side and other hand of the therapist is placed at posterior aspect of the scapula of affected side
- The upper trunk in rotated to the contralateral side of involvement.
- The therapist reaches for the barrier, once barrier is reached the thrust is applied from inferior aspect of the ASIS directed posterior ,superior & lateral.
The thrust places the innominate at its original position.
C.Muscle Energy Technique(Fig.13):-
Subject’s position:-The subject is in crook lying position.
Therapist/ Clinician’s position:-The therapist stands at the side of the couch at ipsilateral side of involvement.
- The therapist places the forearm posterior to the distal thigh.
- The subject is asked to press the forearm of the therapist down (The hip is attempted to be taken for extension and the muscular effort is 1/3rd of the maximal muscular contraction)
- The maneuver is repeated for 4-6 times.
With the muscular contraction as the femoral movement is not allowed so the muscles (Gluteus Maximus & Hamstrings) pulls the innominate for posterior rotation thereby correcting the anterior rotation.
A.Mobilisation in Side lying position (Fig.14)
Subject’s position:- The subject is in the side lying position (affected side placed up).
Therapist/clinician’s position:- The therapist stands behind the subject.
- Therapist places the palm on the lateral aspect of the anterior innominate.
- The pressure is applied anterior and medial.
With the maneuver the gap between the umbilicus and the ASIS decreases reducing the stress to the posterior aspect of the SI joint which is more sensitive.
B.Muscle Energy Technique for out –flare correction ( Fig.15)
Subject’s position:-The subject is in crook lying position.
Therapist’s/Clinician’s position:-The therapist stands at the side of the couch (ipsilateral to the involved side).
1. The subject’s hip is taken for adduction & internal rotation.
2. Barrier is reached.
3. Subject is asked bring the hip for abduction & external rotation (1/3rd of the muscular effort is applied and restricted by the therapist).
4. The contraction is held for 6-10 seconds and repeated for 6-10 times.
C.Core Stability training for the Out-Flare ( Fig.16)
Subject’s position:-The subject is in supine lying position.
Therapist’s/Clinician’s position:-The therapist stands at the side of the couch.
1. The subject’s hip and knee are taken for 90 degrees of flexion each by the therapist.
2. The therapist facilitates the bracing of the lumbar region by facilitation of the transversus abdominis.
3. The therapist withdraws the support and asks the subject to maintain the position. The position is maintained for 6-10 seconds. This position is called as table-top.
The Mechanical dysfunctions of the sacroiliac joint is very common in the present era. The manual therapy methods play a major role for assessment and treatment of the sacroiliac joint dysfunctions. The techniques must be applied meticulously for best of clinical outcome. Precise training and practice is must before applying these highly skilled techniques.
The author recognizes the contributions of MTFI staff members Dr. Uttam Tiwary, Dr. Vishal Goel, Dr. Bhavya, Dr. Swati and Ms. Shilpa for their help in photography and preparation of the manuscript.
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