Sacroiliac joint dysfunction

By:
Yosra Mohammed Hussien (OPT)
Introduction
 The pelvis is the kinetic and kinematic center of the musculoskeletal system.

 The kinematic chains (movement chains) of the vertebral column and the

lower limbs meet here.

 The pelvis must be able to withstand a variety of biomechanical demands,

especially when the body is in upright position.

 Vleeming state that: "The body's core stability starts in the pelvis so that the

three levers-legs and vertebral column-can be moved safely!“

Yosra Mohammed Hussien(OPT)- Al-Neelain University/ Faculty of Physiotherapy 08/14/2022 2

 Functional Anatomy
Pelvis is an unit that is composed of different parts:

1. L4-L5: is considered as a part of pelvis because its strong

attachment to ilium by iliolumbar ligament.

2. Two innominate bones: connected to each other anteriorly by

symphysis pubis.

3. Sacral bone: connected to the 2 iliac bone by 2 sacroiliac joints

4. All the related soft tissue

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Articulations
1. Pubic symphysis

2. Sacroiliac: movement of
sacrum within innominates

3. Iliosacral: movement of
one innominate on sacrum

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Pubic Symphysis
 Strong ligaments

 Small amount of motion

 Rotation

 Traction, compression

 Superior, inferior shear

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 Sacroiliac Joints
 The are weight-bearing joints between the articular surfaces of
the sacrum and ilium.

 They are part synovial joint and part syndesmosis, with the synovial portion being

the anterior and inferior one-third of the joint.

 There is hyaline cartilage on the sacral side and fibrocartilage on the iliac side.

 The ability of the SI joint to self lock occurs through two types of closure:

 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.

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Sacroiliac Joint

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Ligaments
 Much of the integrity of the sacroiliac joint depends on ligamentous structures.

 Here they are organized according to their mechanical importance:

 Iliolumbar ligament

 Interosseous sacroiliac ligaments

 Sacrotuberous, sacrospinous ligaments

 Long posterior sacroiliac ligament

 Anterior sacroiliac ligaments (reinforce the capsule)

 Posterior sacroiliac ligaments

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Ligaments

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 Muscle Function
 Sacroiliac joint movement is mainly passive in response to the action of surrounding muscles.

 The fascia and muscles within the region provide significant self bracing and self locking to

the SI joint and its ligaments through their cross like anatomical configuration; it is formed

ventrally by the external abdominal oblique, linea alba, internal abdominal oblique and

transverse abdominals; dorsally the latissimus dorsi, thoracolumbar fascia, gluteus maximus

and iliotibial tract contribute significantly.

 The psoas and piriformis muscles pass anterior to the sacroiliac joints, and imbalance of

these muscles in particular may affect sacroiliac joint function.

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 Piriformis “assisted by ipsilateral gluteus maximus:

 Anterior tilt and rotate sacrum to opposite side

 Contralateral latissimus dorsi and gluteus maximus through LDF:

 Nutation of sacrum and extension of LS junction

 Long head of biceps:

 Backward tilt and rotate sacrum to same side

 Longissimus and multifidus:

 Pull sacral base superiorly and posteriorly through dorsal ligaments

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Yosra Mohammed Hussien(OPT)- Al-Neelain University/ Faculty of Physiotherapy 08/14/2022 12
 Sacroiliac Joint Axes

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1. Superior transverse axis:

 In posterior sacroiliac ligament at the level of S1 but superior to middle

axis
 Motion: cranio-respiratory sacral motion:

1. Sacral respiratory motion:

 Counternutation with inhalation

 Nutation with exhalation

2. Craniosacral rhythm:

 Cranial flexion with sacral extension / Counternutation

 Cranial extension with sacral flexion / nutation

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2. Middle transverse axis:

 Located anteriorly at the level of S2

 Motion: Flexion(nutation)/ Extension (counternutation) in response to

spinal motion.

3. Inferior transverse axis:

 Located below PSIS , At the level of inferior lateral angle

 Motion: is the axis about which the iliac bone rotate on the sacrum

4. Vertical axis:

 Is located at the middle of sacral bone.

 Motion: is the axis about which unilateral sacral motion occur

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5. Right oblique axis:
 Extend from the level of right S1 to the level of left S3

 Motion: sacral motion during gait occur about oblique axis (right stance limb)

 There are two motion occur about RT oblique axis :

1. Right on right (forward sacral torsion)

2. Left on right (backward sacral torsion)

6. Left oblique axis:

 Extend from the level of left S1 to the level of right S3

 Motion: sacral motion during gait occur about oblique axis (left stance limb)

 There are two motion occur about left oblique axis:

1. Left on left (forward sacral torsion)

2. Right on left (backward sacral torsion)

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Oblique Axes & Gait
 From a standing (neutral) position, when you take a step forward, your

weight is shifted onto one lower extremity.

 This induces spinal column side bending to the weight bearing side, and pins

the upper pole of the sacrum on the side of the side bending.

 As the free lower extremity swings forward, it carries the free pole of the

sacrum anterior, creating rotation of the sacrum about the oblique Axis,
towards the weight bearing extremity.

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Yosra Mohammed Hussien(OPT)- Al-Neelain University/ Faculty of Physiotherapy 08/14/2022 18
 Normal Gait Mechanics
 Innominate:

 Right innominate rotates anteriorly

 Sacrum rotates toward it and side-bends away from it

 Sacrum moves into right forward torsion on right oblique axis the returns to

neutral

 L5 rotates and right sidebends as sacrum right rotates and left sidebends.

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 In the normal gait cycle, there are combined activities that occur conversely

in the right and left innominate bones, and function in connection with the
sacrum and spine.

 Throughout this cycle there is also rotatory motion at the pubic symphysis,

which is essential to all normal motion through the joint.

 In static stance, when one bends forwards and the lumbar spine regionally extends,

the sacrum regionally flexes, with the base moving forward and apex moving
posterior.

 During this motion, both innominates go into motion of external rotation and out

flaring.
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Reciprocal Movement at Lumbosacral Junction

 Flexion of L5-S1:

 Sacral base moves posteriorly into extension (counternutates)

 Extension of L5-S1:

 Sacral base moves anteriorly into flexion (nutates)

 Right rotation and left side-bending of L5:

 Sacral base rotates to left and side bends right

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Sacroiliac Motions
 Two planes:

1. Sagittal plane:
 Nutation

 Counter-nutation

2. Oblique plane:
 Anterior torsion (left on left, right on right)

 Posterior torsion (left on right, right on left)

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 Nutation (flexion) “Sacral locking”
 Base of sacrum moves into pelvis inferoposterior glide

of articular surface of sacrum on ilium coronal axis of

interosseous ligament

 Iliac bones approximate, ischial tuberosities spread

 Limited by interosseous, anterior sacroiliac,

sacrotuberous and sacrospinous ligaments

 Bilateral: Early trunk extension, End range trunk

flexion, Exhalation

 Unilateral: Hip flexion

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Counter-Nutation (extension) “Sacral unlocking”
 Backward motion of base of sacrum out of pelvis

 Anterosuperior glide of articular surface of sacrum on

illium coronal axis of interosseous ligament

 Iliac bones spread, ischial tuberosities approximate

 Limited by long posterior sacroiliac ligament and

multifidus contraction

 Bilateral: Early trunk flexion, End of trunk extension,

Inhalation

 Unilateral: Hip extension

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Left on Left Torsion
 Sacrum rotates left on left
oblique axis

 Right sacral base moves

anterior

 Left ILA moves posterior

 Occurs during gait

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Right on Right Torsion
 Sacrum rotates right on right

oblique axis

 Left sacral base moves

anterior

 Right ILA moves posterior

 Occurs during gait

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Left on Right Torsion

 Sacrum rotates left on

right oblique axis

 Left sacral base moves

posterior

 Left ILA moves posterior

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Right on Left Torsion

 Sacrum rotates right on left

oblique axis

 Right sacral base moves

posterior

 Right ILA moves posterior

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Iliosacral Motion
1. Sagittal Plane:
 Anterior rotation

 Posterior rotation

2. Frontal Plane
 Up-slip

 Down-slip

3. Transverse Plane
 In-flare

 Out-flare
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Iliosacral Motion (sagittal plane)
1. Anterior Rotation:
 ASIS moves inferior

 PSIS moves superior

2. Posterior Rotation:
 ASIS moves superior

 PSIS moves inferior

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SIJ DYSFUNCTION
 SI joint dysfunction refers to an abnormal function (e.g. hypo or hypermobility)

at the joint, which places stresses on structures in or around it.

 It is a significant source of pain in 15% to 30% of mechanical low back pain

sufferers.

 Therefore sacroiliac joint dysfunction may contribute to lumbar, buttock,

hamstring or groin pain.

 It occurs when there is an alteration of the structural or positional relationship

between the sacrum upon a normally positioned ilium.

 It’s not a synonym of sacroiliitis.

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Osteopaths describe a number of dysfunctions associated with
hypo mobility:

 Innominate shears, superior and inferior

 Innominate rotations, anterior and posterior

 Innominate in-flare and out-flare

 Sacral torsions, flexion and extension

 Unilateral sacral lesions, flexion and extension

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Sacral Torsion
Forward Torsion (L on L): Backward Torsion (R on L):

 Restricted nutation (flex) of right  Restricted counter-nutation of the

sacral base right sacral base

 Static findings:  Static Findings:

 Sacral base deep right  Sacral base shallow right

 Sitting flexion test positive right  Seated Flexion test positive right

 Right sacral base anterior, more  Sacral base posterior right, worse in

level in extension extension

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 Etiology Precipitating Factors
Sources of sacroiliac joint  Muscle imbalance between the hip
pain include: flexors and extensors or between
 Spondyloarthropathies
the external and internal rotators
 Crystal arthropathy
of the hip
 Septic arthritis
 Leg length imbalance
 Trauma
 Biomechanical abnormalities, such
 Pregnancy diathesis

 Mechanical joint Dysfunction

as excessive subtalar pronation.

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Differential diagnosis
 Rheumatologic disorders  Ankylosing spondylitis

 Infection  Lumbosacral facet syndrome

 Neoplasms  Spondyloarthropathy

 Sacral stress fracture

 Trochanteric bursitis
 Radicular pain
 Hip fracture
 Piriformis syndrome
 Hip overuse syndrome

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Clinical Features
 Low back pain below L5.

 The pain is usually restricted to one side but may occasionally be bilateral.

 Pain commonly refer to the buttock, groin and posterolateral thigh,

occasionally, may refers to the scrotum or labia.
 Broadhurst describes it a clinically useful description that:
 Patient has deep seated buttock pain
 Difficulty in stairs climbing and problems rolling over in bed
 Triad of signs:
 Pain over the SI joint
 Tenderness over the sacrospinous and sacrotuberous ligaments
 Pain reproduction over the pubic symphysis.

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Physical Examination
 The physical examination should begin with observation both statically and

dynamically.

 The patient should be evaluated in different positions, and symmetry

assessed in the heights of the landmarks.

 Leg length discrepancy should be assessed: dynamic observation may reveal

a decrease in stride length with walking, leading to a limp, or a

Trendelenburg gait due to reflex inhibition of the gluteus medius.

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 True leg length discrepancies will generally cause asymmetry and pain,

whereas a functional leg length discrepancy is usually the result of SI joint

and/or pelvic dysfunction.

 Muscle strength and flexibility should be assessed.

 Full assessment of the hips and lumbar spine should also be

performed.

 The presence of trigger points in surrounding muscles should be

noted.

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Palpation

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PELVIC LANDMARK PALPATION

 ASIS Level

 PSIS Level

 Iliac Crest Level

 INTERPRETATION

 All Landmarks Level -----NORMAL

 All Landmarks High on One
Side----LEG LENGTH DISCREPANCY
 Asymmetrical Height
Differences---SI DYSFUNCTION

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41
Special Tests

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Positional Tests
Landmarks

 ASIS

 PSIS

 Sacral sulcus

 ILA

 Medial malleoli (prone)

 L5

 Pubic tubercle

 Gluteal folds

Positions

 Neutral, extended and flexed

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 Pain Provocative Tests
Faber’s test Gaenslen’s test
 Anterior gapping (Distraction)

 Posterior gapping

(Compression)

 Gaenslen’s

 Thigh thrust

 Sacral thrust

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 Sacral thrust test Thigh thrust test

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 Compression test

Distraction test

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  Spring test:
• Find sacral base. Place heel of hand over Lumbosacral
junction. Spring in an Anterior motion. Results:
• Positive test If there is NO springing allowed;
Non-neutral Condition (Backward torsion)
• Negative test If there is springing allowed;
Neutral condition.

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Active Motion Tests
 Standing flexion test

 Stork test (Gillet’s test)

 Seated flexion test (Piedallu’s test)

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Standing Flexion test
 PSIS palpated in standing
position

 PSIS palpated in flexed position

 Interpretation:

 Change in relative position SI

DYSFUNCTION

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Gillet (Stork) test
 PSIS palpated in standing

 Patient is asked to flex one hip

towards the chest

 Interpretation:

 Normal: PSIS moves inferiorly

 Positive test: PSIS does not move

or moves cranially

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Sitting Examination
1. Landmark Palpation:
 Palpation of PSIS repeated in Sitting

 Interpretation:

 Asymmetry Sacroiliac Dysfunction

2. Sitting Flexion Test

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Seated Flexion (Piedallu’s) test
 PSIS palpated in sitting position

 PSIS palpated in flexed position

 Interpretation:

 Change in relative position:

Sacroiliac Dysfunction

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Yosra Mohammed Hussien(OPT)- Al-Neelain University/ Faculty of Physiotherapy 08/14/2022 52
Supine Examination
Long-Sit Test

 Medial malleoli assessed in

supine

 Medial malleoli assessed in long

sitting

 Interpretation:

 Change in relative position =

sacroiliac dysfunction
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Yosra Mohammed Hussien(OPT)- Al-Neelain University/ Faculty of Physiotherapy 08/14/2022 54
Prone Examination
 Prone Knee Bend Test:

 Heels assessed in prone with knees extended

 Heels assessed in prone with knees flexed

 Interpretation:

 Change in relative position = Sacroiliac Dysfunction Palpation (extension)

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Yosra Mohammed Hussien(OPT)- Al-Neelain University/ Faculty of Physiotherapy 08/14/2022 56
 Sacral Sulcus Palpation Sacral Sulcus Palpation
(neutral) (extension)

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Imaging
 CT and MRI are often used to confirm the diagnosis.

 There is no specific gold standard imaging test to diagnose SI joint dysfunction due

to the location of the joint and overlying structures that make visualization
difficult.

 By using fluoroscopically guided sacroiliac joint blocks to confirm cases of

sacroiliac joint pain, several authors have shown that clinical medical history and
pain provocation tests are not reliable in the diagnosis of sacroiliac joint pain.

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 Correction
 Due to the complex nature of the SI joint and its surrounding structures, treatment

must focus on the entire abdomino-lumbo-sacro-pelvic-hip complex, addressing

articular, muscular, neural and fascial restrictions, inhibitions and deficiencies.

 First stage of the treatment the aim is to reduce the inflammation with icepacks,

anti-inflammatory medication and use sacroiliac belt if severe.

 A second important goal is to improve mobility using mobilizations, manipulation or

exercise therapy.

 Finally, postural and ergonomic advice will help the patient to decrease the risk of

reinjury.
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 Sacroiliac Belt
 If there are complaints of
instability, it can be useful to
make use of a sacroiliac belt to
temporarily support the pelvis,
together with progressive
stabilization training to
increase motor control and
stability.

 If the sacroiliac joint is

severely inflamed, a sacroiliac
belt can also be used.
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Physiotherapy
Treat the innominate (iliosacral) dysfunction first, when unresponsive consider

Sacroiliac Dysfunction.

Exercise:

 Core stability training should be included.

 Stretching and soft tissue therapy are useful in correcting pelvic/ SI joint

imbalance. The most common soft tissue abnormality found with unilateral
anterior tilt are tight psoas and rectus femoris muscles.
Muscle energy technique

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Manipulation
 The patient lies on his back with the therapist standing opposite the side to

be manipulated.

 The patient places his hands behind his head and the therapist then moves

the patient passively into side bending to end range toward the target side.

 The therapist then delivers a quick thrust to the Anterior Superior Iliac Spine

(ASIS) in a posterior and inferior direction (Cleland et al., 2006; Edmond,

2006).

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Yosra Mohammed Hussien(OPT)- Al-Neelain University/ Faculty of Physiotherapy 08/14/2022 63
Exercises
Anterior Rotation Posterior Rotation

 Unilateral hip flexion activities  Unilateral hip extension activities

 Mobilization  Mobilization

 Hip Flexor stretching  Hamstring stretching

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 MET
 Anterior Innominate

 MET

 Move to the end range of

posterior rotation (hip flexion)

 Contract into hip extension

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 MET
 Posterior Innominate

 MET

 Move to the end range of

anterior rotation (hip

extension)

 Contract into hip flexion

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 Soft tissue therapy technique to reduce psoas tightness; sustained longitudinal

pressure is applied to the psoas muscle fibers superior to the inguinal ligament
with the hip initially flexed and slowly moved into increased extension. 

 Osteopathic manipulation; using the Chicago technique.

 Sacroiliac belts;  it is wrapped around the hips to hold the sacroiliac joint

tightly together, which may ease SIJ pain.

 Taping provides support to the SI joint and alleviates pressure on the nerves in

this region. Pain relief is felt immediately and continues to improve with use.

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Correction/ Medical
 If these manual techniques fail to control the sacroiliac pain, injection

therapy may prove useful.

A combination of local anesthetic and corticosteroid agents may be

injected into the region of the SI joint, either with or without fluoroscopic
guidance.

 Sclerosants, are occasionally used when hypermobility is present,

sometimes referred to as prolotherapy. 

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 THANK YOU
69

Yosra Mohammed Hussien(OPT)- Al-Neelain University/ Faculty of Physiotherapy 08/14/2022