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Sacroiliac Joint Dysfucntion

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by

Ray Lamb

on 11 March 2015

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Transcript of Sacroiliac Joint Dysfucntion

Sacroiliac Joint Dysfunction
By: Ray Lamb
Outline for Today
Anatomy of the Pelvis/SIJ
Examination:
Diagnostic Clues
Best Special Tests
Palpation/Positioning tests
Treatments
Pt Case Study
Lab
Functional Units of the SIJ
L5-S1
Pubic Symphysis
L5-S1
2 SIJ
2 Ilium/innominate
Pubic symphysis
Sacrum
(Bogduk 1999)
SIJ:
Part synovial, part syndesmosis
For shearing and tensile forces
The surfaces are are irregular (more so in women)
Sacrum is wider dorsally at S1
Sacrum is wider ventrally at S3
Bonnaires tubercle
Bonnaires tubercle:
Prominence on Ilium that is received by S2
Sacrum nutates around in WB
Sacrum is oblique and tilts forward and downward in WB around the Tubercle
Creates a bony locking mechanism
Hmmm...

Movements are very small
Motion occurs from action of muscles moving adjacent bony structures and ground rxn forces

(Bogduk, 1999)
Two main roles of the Sacrum:

1. Longitudinally:
- Supports LS
- Forces from LS are transmitted to the Sacrum

2. Transversely:
- Forces are transmitted sideways <> the Pelvis and LE
- Makes up posterior wall of pelvis
Ligamentous Structures of the SIJ/Sacrum
- most important (Bogduk 1999)
- Bind sacrum to ilium
Connects lateral crest of sacrum to PSIS inner lip of Iliac crest
- helps bind sacrum to ilium
- Mostly prevents posterior flaring of jt
-Long Fibers prevent counter nutation of sacrum

Assess integrity by pushing medially on ASIS
Runs Transversely from Ala to Anterior surface of Ilium
Function:
- Binds ilium to sacrum
- Prevents anterior winging
Assess integrity by pushing laterally on ant aspect of pelvis
Distal lateral aspect of Sacrum to Ischial spine
Function:
- prevent nutation of sacrum
Originates for 4 parts of the Sacrum:
1. PSIS
2. Transverse tubercles of the Lower Sacrum
3. Inferior lateral margin of the sacrum
4. Ischial tuberosity
Continues with the long head of the biceps femoris tendon
Function:
- Prevents nutation of sacrum

*Usually have pain in WB if weak or damaged
*Any muscle that attaches to the pelvis from LS or Femur will affect this ligament
Muscles that affect the SIJ:
Quadratus Lumborum
Psoas
Iliacus
Gluteus Maximus
Biceps Femoris
Adductors
Hip Rotators
Transversus Abdominis
Pelvic Floor muscles
Multifidus
Changes The SIJ undergoes in a lifespan:
0-10 Highly mobile (in vertical plane)
10-30 Jt becomes oblique
30-40 Osteophytes, capsule thickens, DJD starts
50-60 Motion decreases
60-80 Ankylosis
Diagnostic Clues...

Symptom distribution is a poor indicator (Fortin et al, 1994)
Trauma involving long axis through femur or fall on ischial tuberosity
Pain w/ rolling side to side
Pain negotiating stairs
WB activities may be more provocative
Pregnancy or post-partum
81 pt with chronic lumbopelvic pain referred for diagnostic injections.
Significant relationships:
Discogenic pain and centralization:
Repeated movement testing
Pain when rising from sitting
Lumbar z-joint pain:

Absence of pain when rising from sitting.
Sacroiliac joint pain:
Three or more positive pain provocation tests
Pain when rising from sitting,
Unilateral pain and
Absence of lumbar pain
Exam/Special Tests:
0.88 Sensitivity
0.81 Specificity
Mobility/Palpation/Position Testing:
Poor Reliablity & Validity
-Dreyfuss et al, 1994, Potter et al, 1985, Riddel et a;, 2002, & Robinson et al, 2007
Interventions:
Directional preference
LE or Trunk
Muscle Energy Techniques
The more force the better correction
End range is goal
Check response to ADD & ABD
Iliac Rocking
Soft tissue mob:
Sacrotuberous Ligament
Stabilization belt
Lumbopelvic Stabilization TE
TA
Pelvic Floor
Multifidus
Case Study:
- Pt is an older adult w/ c/o of LBP especially in the mornings
- Presents with a R Lateral Shift
- Lumbar Stenosis
- Cont. to demonstrate pain in the morning that eases as the day progresses
-
Findings:
- R aspect of sacrum flares posteriorly
- L PSIS slight elevated
- continued to rise in seated flexion test
-
Interventions:
- Traction
- Muscle energy
- TA, Multifidus, and Pelvic floor
- SI Belt
-
Elimination of pain and Decrease Lateral shift:
- Gaenslen's Test R knee to chest
- Bilateral compression of sacrum in standing
- L hand stabilize sacrum R hand Post rotates R innominate

Citations
Lab:
Don a SI belt
Palpate
Review provocation tests

Movements in the transverse plane:
Flare is identified by movement of ASIS
In-flair coupled w/ hip IR
Out-flair coupled w/ hip ER
My Thoughts:
Retry SI Belt
Muscle energy tech for glute max and piriformis
Continue posterior rotation of R innominate

Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum. Edinburgh: Churchill Livingstone, 1999.

Dreyfuss P, Dreyer S, Griffin J, et al. Positive sacroiliac screening tests in asymptomatic adults. . 1994; 19:1138- 1143.

Jackson, R., & Porter, K. (2011). The Pelvis and Sacroiliac Joint: Physical Therapy Patient Management Utilizing Current Evidence. Current Concepts of Orthopaedic Physical Therapy (3rd ed., p. 18). Middleburg: APTA.

Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. ; 1994; 19:1243 - 1249.

Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. . 2005; 10:207-218.

Laslett M, Young SB, April CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a Mckenzie evaluation and sacroiliac joint provocation tests. . 2003 ; 49:89 -97.

Potter NA, Rothstein JM. Intertester reliability for selected clinical tests of the sacroiliac joint. . 1985; 65:1671 - 1675.

Richardson CA, Snijders CJ, Hides J, et al. The relation between the transversus abdominis muscles, sacroiliac joint mechanics, and low back pain. 2002; 27:399 -405.

Riddle DJ, Freburger JK. Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter Intertester reliability study. ; 82;772 -781.

Robinson HS, Brox JI, Robinson R, et al. The reliability of motion and pain provocation tests for the sacroiliac joint. 2007; 12:72 -79.

Young S, April C, Laslett M. Correlation of clinical characteristics with three sources of chronic low back pain. 2003; 3: 460 -465.
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