Sacroiliac Dysfunction PDF

Dr. Mona Selim Faggal DR. Mona Selim  SACROILIAC JOINT (SIJ) dysfunction The sacroiliac joint (SIJ) is a pain generator  It refers to an abnormal function (e.g. hypo- or hypermobility) at the joint due to altered mechanics , which places stresses on structure...

Dr. Mona Selim Faggal DR. Mona Selim  SACROILIAC JOINT (SIJ) dysfunction The sacroiliac joint (SIJ) is a pain generator  It refers to an abnormal function (e.g. hypo- or hypermobility) at the joint due to altered mechanics , which places stresses on structures in or around the joint and cause pain and discomfort.  Therefore, SIJ dysfunction may contribute to:  lumbar, buttock, hamstring or groin pain. DR. Mona Selim  The sacrum vertebrae.  Five sacral vertebrae are fused to form the triangular or wedge- shaped bone that is the sacrum.  The base of the triangle, supports two articular facets that face posteriorly for articulation with the inferior facets of the fifth lumbar vertebra (that face anteriorly).  The apex of the triangle, formed by the fifth sacral vertebra, articulates with the coccyx. DR. Mona Selim the S1 segment may be mobile. This occurrence is called lumbarization of S1, and it results in a sixth “lumbar” vertebra. At other times, the fifth lumbar segment may be fused to the sacrum or ilium, resulting in a sacralization The lumbosacral angle It is determined by measuring the angle formed by a line drawn parallel to the superior aspect of the sacrum and a horizontal line. Shear stresses at the lumbosacral joint increases with increased lumbosacral angle. DR. Mona Selim  SACROILIAC JOINT The two SIJs are articulations between the first three sacral segments and the two ilia of the pelvis SACRUM: Auricular (C)-shaped on sides of fused sacral vertebrae (concave) Covered with hyaline cartilage Thicker than iliac cartilage  ILIA:(convex) Covered with fibrocartilage DR. Mona Selim  The SIJs are unique in that both the structure and function of these joints change significantly from birth through adulthood.  The sacroiliac joints are relatively mobile in young people, they become progressively stiffer with age.  The child and pre-pubertal:  The articular surfaces are Flat and smooth (can consider as Plane synovial joint with gliding motion in all direction.  Post pubertal:  Become irregular as, the joint surfaces of the ilium develop a central ridge that corresponds to the grooves on the sacrum, fitting together like pieces of a puzzle (form closure) DR. Mona Selim DR. Mona Selim 1. Interosseous SI ligament Strong & massive Superficial & Deep 2.Anterior Sacroiliac Ligament 3. Posterior Sacroiliac Ligament Stronger than anterior ligament and connects sacrum to PSIS. 4. Sacrospinous Ligament Connects ischial spines to lateral borders of sacrum and coccyx Forms inferior border of greater sciatic notch 5. Sacrotuberous Ligament Connects the ischial tuberosities to lateral sacrum and coccyx Forms inferior border of lesser sciatic notch.  FUNCTION OF SACROILIAC JOINT 1- Connects spine to pelvis. 2- Absorbs vertical forces from spine and transmitting them to pelvis and lower extremities (stress relive junction)  Close pack: Nutation (with the base moving forward and the apex moving posterior)  Loose pack: Counter-nutation DR. Mona Selim  KINEMATICS Very slight motion is available and it is best regarded as a stress-relieving joint Rotational motion : 2.5° Translation motion : 0.3 to 0.7 mm or 1 cm  The SIJs are linked to symphysis pubis. Any motion at symphysis pubis is accompanied by motion at SIJs and vice versa During pregnancy: ROM increase in which all ligaments of pelvis become loose under influence of hormones, to facilitate delivery of fetus DR. Mona Selim Movements of the sacrum Nutation (sacral locking): is the forward motion of the base of the sacrum into the pelvis or the backward rotation of the ilium on the sacrum It is the most stable position of the sacroiliac joint and is an example of form closure. Nutation is limited by:  the anterior sacroiliac ligaments  the sacrospinous ligament,  the sacrotuberous ligament DR. Mona Selim Pathologically, if nutation occurs only on one side:  Normally it should occur bilaterally you will find that the anterior superior iliac spine (ASIS) is higher and the posterior superior iliac spine (PSIS) is lower on that side.  The result is an apparent or functional short leg on the same side. DR. Mona Selim  Counternutation (sacral unlocking), or contra-nutation  It is the opposite movement to nutation.  It is an anterior rotation of the ilium on the sacrum or backward motion of the base of the sacrum out of the pelvis  Counternutation is limited by: the posterior sacroiliac ligaments.  Counternutation occurs: when a person assumes a “lordotic” or “anterior pelvic tilt” position.  Pathological or abnormal counternutation on one side occurs when the ASIS is lower and the PSIS is higher on one side. DR. Mona Selim DR. Mona Selim DR. Mona Selim  Kinetics  Stability of the SIJs is extremely important because these joints must support a large portion of the body weight.  Form closure: describes how specifically shaped, closely fitting contacts provide inherent stability independent of external load.  Force closure: describes how external compression forces add additional stability.  The force of the body weight creates a nutation torque on the sacrum.  Stability of the SIJs is provided by the ligamentous tension and from adjacent muscles that reinforce the joint capsules and blend with the ligaments. DR. Mona Selim  Active Stability of SIJ  The sacroiliac ligaments, are reinforced by fibrous expansions from the quadratus lumborum, erector spinae, gluteus maximus, gluteus minimus, piriformis, and iliacus muscles A connection between the biceps femoris muscle and the sacrotuberous ligament allowing the hamstring to play an integral role in the intrinsic stability of the SIJ. The biceps femoris, which is frequently found to be shortened on the side of the SIJ dysfunction, may act to compensate to help stabilize the joint. DR. Mona Selim  The cross-like configuration demonstrating the force closure of the sacroiliac joint This load transfer is critical during rotation of the trunk, helping to stabilize the lower lumbar spine and pelvis. Dorsally Ventrally The anterior oblique muscle system of the outer group The posterior oblique muscle system of the outer group (includes the external and internal obliques, and transverse (includes the latissimus dorsi, gluteus maximus, and abdominals with contralateral adductors of the thigh, and thoracolumbar fascia). anterior abdominal fascia). DR. Mona Selim  Precipitating factors for the SIJ disorders Muscle imbalance: Hip flexors and extensors. ( the most common found abnormality is tight psoas and rectus femoris muscles) Hip external and internal rotators of the hip.  leg length imbalance. (True leg length discrepancies will generally cause asymmetry and pain, whereas a functional leg length discrepancy is usually the result of SIJ and/or pelvic dysfunction) DR. Mona Selim  Clinical Evaluation Where is the pain ? SIJ pain classically describes as: deep, dull, undefined pain tends to be unilateral  low back pain below L5. Pain can refer to the buttock, groin and posterolateral thigh. History: Onset: Acute or insidious **Mechanism: Was there any known mechanism of injury? stepping off a curb or fall on the buttocks Prolonged stress DR. Mona Selim  Biomechanical abnormalities: e.g. excessive subtalar pronation & scoliosis.  Postpartum women: It may take 3 to 4 months or longer for the ligaments to return to normal state ( Relaxin hormones which is responsible for the softening of the ligaments supporting the SIJs and the symphysis pubis.)  Rheumatoid arthritis, or ankylosing spondylitis  Anxiety, depression, and other psychosocial issues DR. Mona Selim  Symptoms  Stiffness and pain with prolonged walking or standing(specially unilateral), single leg squat Pain with standing from a sitting position Difficulty & pain in climbing or descending the stairs  Pain in turning in bed, getting out of bed, or stepping up with the affected leg. Tenderness over SI joints and PSIS Pain reproduction over the pubic symphysisDR. Mona Selim ◦ Inspection:  Levels of iliac crests, ASIS, PSIS.  Leg length discrepancy should be assessed. ◦ Palpation:  Pain over SI joints and PSIS ◦ Functional tests ◦ Full assessment of the hips and lumbar spine should also be performed. ◦ Neurological testing:  Lower quarter screen ◦ Special tests:  Mobility tests (Standing, Seated Flexion , Gillet’s tests)  Pain Provocation Tests (SI compression and distraction; straight leg raising;  FABRE; Gaenslen’s; quadrant tests) DR. Mona Selim  Palpation  Anteriorly:  Iliac crest and Symphysis pubis and ASIS Posteriorly:  PSIS and ischial tuberosity  The S2 spinous process is at the level of a line joining the two PSISs (“posterior dimples”). DR. Mona Selim Mobility testing of the sacroiliac joint: 1-Active Motion Tests 1-Forward flexion test Aim:  to test mobility of the sacroiliac joint DR. Mona Selim 2-Seated Flexion Test (mobility of the sacrum) Aim:  This is a mobility test for the sacrum moving on the ilium.  This test eliminates the influence of the lower extremities. DR. Mona Selim 3-Gillet’s (Sacral Fixation) Test. ( mobility of the ilium)  This test is also called the ipsilateral posterior rotation test. Aim:  to test sacroiliac hypomobility DR. Mona Selim A, Examiner places the left thumb on the posterior superior iliac spine (PSIS) and the right thumb over one of the sacral spinous processes. B, With normal movement, the examiner’s left thumb moves downward as the patient raises the left leg with full hip flexion. C, If the joint is fixed, the examiner’s left thumb moves upward as the patient raises the left leg. DR. Mona Selim  Passive movement—hip quadrant. The hip joint is placed into the quadrant position,  which consists of flexion, adduction and internal rotation DR. Mona Selim  Test Position:  Patient standing with feet shoulder width apart  Examiner stands behind the patient, grasping the patient’s shoulders  Action:  Patient extends the spine as far as possible, than side bends and rotates to affected side  Examiner provides overpressure through the shoulders, supporting the patient as needed  Positive Findings:  Reproduction of patient’s symptoms  Symptoms isolated to the area of the PSIS may indicate SI joint dysfunction  Anterior gapping (Distraction)Test: ◦ Test position:  Subject supine; examiner stands next to subject and with arms crossed, places heel of both hands on the subject’s ASISs ◦ Action:  Examiner applies outward and downward pressure with the heels of both hands ◦ Positive finding:  Unilateral pain at SI joint or in gluteal region is indicative of anterior SI ligament sprain DR. Mona Selim  Sacroiliac Joint Stress Test (Compression in sideling): ◦ Test position:  Subject side-lying; examiner stands next to patient and places both hands (one on top of the other) directly over the subject’s iliac crest ◦ Action:  Apply downward pressure ◦ Positive finding:  Increased pain indicative of SI pathology (possible involvement of posterior SI ligament) DR. Mona Selim  Sacroiliac Joint Stress Test: ◦ Test position:  Subject lying supine; examiner places both hands on lateral aspect of subject’s iliac crests ◦ Action:  Apply inward and downward pressure ◦ Positive finding:  Increased pain indicative of SI pathology (possibly involving posterior SI ligaments) DR. Mona Selim  Patrick or FABER Test: ◦ Test position:  Subject supine ◦ Action:  Examiner passively flexes, abducts, and externally rotates the involved leg until the foot rests on the top of the knee of uninvolved lower extremity; examiner slowly abducts the involved lower extremity towards the table ◦ Positive test:  Involved lower extremity does not abduct below level of uninvolved side  iliopsoas tightness  Pain with downward pressure indicates a sacroiliac joint problem DR. Mona Selim  Gaenslen’s Test: ◦ Test position:  Subject supine, lying close to edge of table; examiner stands at side ◦ Action:  Slide patient to edge of table; patient pulls far knee up to the chest; near leg allowed to hang over edge of table  Examiner applies downward pressure on near leg, forcing it into hyperextension ◦ Positive finding:  Pain in SI region in the hyperextended side indicating SI joint dysfunction DR. Mona Selim  Clinical prediction rule (CPR) Clinical probability assessment specifies how to use medical signs, symptoms, and other findings to estimate the probability of a specific disease or clinical outcome. For SIJD, three or more positive tests had high levels of sensitivity and specificity. DR. Mona Selim  Treatment 􀂄􀂄 Muscle energy techniques 􀂄􀂄 Joint mobilization 􀂄􀂄 Joint manipulation 􀂄􀂄 Muscle stretching 􀂄􀂄 Trunk stabilization (Core stability) Sacroiliac belts have not been shown to be particularly helpful. DR. Mona Selim  The most common soft tissue abnormalities found with unilateral anterior tilt are tight psoas and rectus femoris muscles. Ischemic pressure with the elbow to the hip abductors Sustained longitudinal pressure is applied to the psoas muscle with the hip initially flexed and slowly moved into increased extension DR. Mona Selim  SIJ Mobilization techniques Aims: To increase ROM at the sacroiliac joint  To decrease pain To increase accessory motion in the sacroiliac joint Correction of positional faults. To examine for sacroiliac joint impairment DR. Mona Selim  Grade I ◦ Small amplitude movement at the beginning range of joint play ◦ Used when pain and spasm limit movements early in ROM  Grade II ◦ Large amplitude movement at the midrange of the joint play ◦ Used for pain control, spasm reduction which inhibit movement  Grade III ◦ Large amplitude movement at the end-range of joint play ◦ Reduce pain, increase periarticular extensibility, and correct positional faults  Grade IV ◦ Small amplitude movement at the end-range of joint play ◦ Reduce pain, increase periarticular extensibility, and correct positional faults  POSTERIOR GLIDE OF THE ILIAC CREST  Correction of an ilio-sacral joint anterior rotation positional fault.  Procedures:  The mobilizing/manipulating hand glides the anterior superior iliac spine and the anterior surface of the iliac crest in a posterior direction.  The guiding hand guides the ischium anteriorly. DR. Mona Selim  ANTERIOR GLIDE OF THE ILIAC CREST Correction of an ilio-sacral joint posterior rotation positional fault.  The mobilizing/manipulating hand glides the iliac crest anteriorly.  The guiding hand guides the anterior and lateral surface of the pelvis posteriorly. DR. Mona Selim  SACRAL ANTERIOR GLIDE The mobilizing hand (the base ) of the sacrum anteriorly, directing the sacrum into flexion (nutation). DR. Mona Selim  SACRAL POSTERIOR GLIDE The mobilizing/manipulating hand glides (the apex) of the sacrum anteriorly, directing the sacrum into extension (counternutation). DR. Mona Selim  Correction of Bilateral Anterior Nutated Sacrum 􀂄􀂄􀂄􀂄 Patient seated 􀂄􀂄􀂄􀂄 Feet apart 􀂄􀂄􀂄􀂄 Patient flexes forward 􀂄􀂄􀂄􀂄 Your hands on sacral apex Maintain pressure on sacral apex and resist trunk extension with full inhalation DR. Mona Selim  Correction of Bilateral Posterior Nutated Sacrum 􀂄􀂄􀂄􀂄 Patient seated 􀂄􀂄􀂄􀂄 Feet together 􀂄􀂄􀂄􀂄 Arms crossed 􀂄􀂄􀂄􀂄 Your hands on sacral base Maintain pressure on sacral base and resist trunk flexion with full exhalation. DR. Mona Selim DR. Mona Selim