Download upload/uploads/upload-1197282898-GP SIJ

SIJ – A COMMON
CAUSE OF LBP?
Kathryn Dunbar
Clinical Specialist
Connect Physical Health Centres
AIMS
To give a basic understanding of the
SIJ and how to identify a dysfunction
AIMS
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Does the SIJ move?
Anatomy, stability and function
Predisposing factors
Symptoms, aggravating and easing
factors
Quick examination techniques
Piriformis syndrome
Treatment and advice
THE PELVIS
Pelvic Girdle
Osseo cartilaginous ring made up from
sacrum, coccyx and 2 innominate bones
Joints within or on the girdle:
 Pubic Symphysis
 Sacroiliac joints
 Hip joints
 L5 / S1
SACRUM
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Varies in shape
Can be more triangular – greater
stability
More rectangular – less stability
Frequent bony anomalies
Does the SIJ move?
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Part synovial, part fibrous
Sacral surface is covered by articular
(hyaline) cartilage
The ilium’s surface is covered by fibrocartilage
Both surfaces are reciprocal although they
are very irregular and not congruent
There is a disc like substance found in
30% of SIJ’s
STABILITY
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For walking the SIJ needs optimal joint mobility as well as
stability
The shape of the sacrum and innominates and the irregularity
of the joint surfaces give some form closure
Several muscles, ligaments and the thoraco-lumbar fascia all
contribute to force closure (compression)
This combination of form and force closure is termed as selfbracing or self-locking mechanism
Functions of the Sacroiliac Joint
1.
Transmission of forces from the trunk through the
lumbo-sacral junction to the sacrum.
2.
Shock absorption
There is evidence of increased disc degeneration in
the lumbar spine after deterioration of the SIJ. (Shaw
1992 and Scholten 1988)
3.
Stability of the pelvis.
4.
The pelvis provides protection to the viscera and
foetus in pregnancy
DYSFUNCTIONS OF THE SIJ
1.
Of 88 patients with low back pain, 71 (88%) had evidence
of SIJ dysfunction. 73% of the 71 had unilateral low back
pain." Cibulka 1992
2.
In our study of 1,000 consecutive patients with low back
pain, 98% had a mechanical dysfunction of the sacroiliac
joints as a major cause of their LBP."Joseph L. Shaw 1992
3.
The presence of unilateral low back pain alerts the
clinician that a patient may have a sacroiliac problem."
Greenman 1992, also Bourdillon 1982, Wells 1986,
Ramamurti 1979, Cibulka 1992.
HISTORY
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Pregnancy / childbirth
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Menopause
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Following gynae examination or obs and gynae
surgery
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Bladder ops, prostatectomy
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Repetitive movements involving twisting in forward
stoop position or sitting forward, lateral lifting
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e.g. nurse, physio, housewife, desk worker, check out
operator in shop
HISTORY
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Sport – e.g. golf, athletics, fast bowling, football,
horse riding, martial arts, aerobics, rowing
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Trauma – lifting, fall onto ischial tuberosity / coccyx,
fracture around pelvis, femur, lumbar spine, stepping
down heavily, RTA, post THR
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Stiff hips, stiff lumbar spine, tight hamstrings, poor
core stability, actual LLD, hypermobility
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Standing unevenly, sitting crossed legged
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Hamstring problems, recurrent groin strains and
lower abdominal tears and conjoint tendon problems
SYMPTOMS
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Usually unilateral pain, more often felt below the
level of the iliac crest
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Referral into buttock, lower abdomen, groin, pubis,
posterior thigh, medial thigh
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Pain from SIJ can be felt below knee to the foot
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‘Sciatic nerve’ symptoms from piriformis syndrome
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Pins and needles in buttock from sacrotuberous
ligament syndrome
SYMPTOMS
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Local pain over SIJ can be minimal
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Pubic symphysis can cause groin pain radiating to
the medial thigh
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Clicking over pubic symphysis
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Anaesthesia / paraesthesia
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N.B. Check for testicular symptoms, abdominal
symptoms, saddle anaesthesia, urinary symptoms,
Gilmore’s groin
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Be aware that SIJ and Lumbar spine problems can
coexist
BEHAVIOUR OF SYMPTOMS
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Can be constant or intermittent with any degree of severity and
irritability
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Dull aching or stabs of pain
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Hind quarters feel twisted, out of place
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Leg can feel heavy, dead
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Giving way (can be due to dysfunction of iliopsoas, diastasis or
hypermobility)
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SIJ asymmetry can inhibit pelvic floor function and may be
responsible for the secondary coccydinia experienced by a
number of patients with pelvic girdle dysfunction
AGGRAVATING FACTORS
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Weight bearing
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Stand on one leg
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Rolling over in bed
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Walking
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Running
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Jumping
AGGRAVATING FACTORS
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Sit stand
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Sit crossed legged
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Prolonged position
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In and out of car
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Coughing can increase pain with hypermobile SIJ’s
and especially with pubic symphysis diastasis
(distinguish by compression through greater
trochanters)
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Groin pain aggravated by kicking, hurdling, step
aerobics, golf swing, crossing legs, horse riding
EASING FACTORS
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Gentle movement
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Changing position
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Sleep with pillow between knees
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Keeping knees together when turning e.g in and out of car
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Foetal position
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Pulling knees to chest
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Sit in posterior pelvic tilt / leaning forwards
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Bath
DIFFERENTIAL DIAGNOSIS
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Constant unvarying night pain
unrelated to movement
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Consider general health
e.g. Appendicitis, UTI’s, Diabetes, Pagets
disease, T.B., evidence of primary neoplasm
elsewhere (breast, bronchial etc), Prostate
Cancer, Avascular necrosis, Reiters disease,
Anky Spon, Psoriatic arthritis, Osteitis pubis,
Osteomyelitis, Inguinal hernia, IBS
EXAMINATION
Palpation
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ASIS’s
PSIS’s
Iliac Crests
Sacral sulcus
Ischial tuberosities
EXAMINATION
Squish Test – Posterior Ilial Glide
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Patient in supine lying
Glide the SI joint in a posteromedial direction in
line with forearms (elbows flexed to 15º)
Slowly glide one side (should take 4-6 secs),
then the other side (do not fix contralateral
side)
Looking for quality and quantity of motion and
end feel
Not looking for pain
Positive test on hypomobile side
EXAMINATION
Leg Length Supine and Long Sit
 Ensure patient is straight on bed
 Check level of medial malleoli in supine
 Ask patient to sit in long sit and assess for
change in medial malleoli levels
 A change indicates SIJ dysfunction
 No change indicates actual leg length
discrepancy
EXAMINATION
Differentiation
Waiters Bow
 If patient complains of pain with Lumbar
flexion, repeat keeping lumbar spine straight.
 If  pain implicates Lumbar spine, if  pain
or no change indicates SIJ or hip
 To differentiate hip further can put foot on a
chair or internally rotate (any change in pain
with lumbar flexion implicates hip)
EXAMINATION
Differentiation
Greater Trochanter compression
 With pain on Lumbar flexion, repeat flexion
with compression through the greater
trochanters.
  pain implicates SIJ
PIRIFORMIS SYNDROME
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Sciatic nerve goes through or under
piriformis
 Sustained tension in this muscle can
lead to the formation of trigger points
resulting in the compression of the
sciatic nerve and possibly the
dysfunction of the SIJ.
 This tension in the Piriformis results in
symptoms that are easily confused with
those of a herniated disc.
 Recognition of piriformis symptoms may
avoid needless laminectomy and
orthopaedic referral.
PIRIFORMIS SYNDROME
Symptoms
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May be a mixture of seemingly unrelated
symptoms.
Pain and paraesthesia may be apparent
in one or more of these areas:
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Lumbar Spine
Groin
Perineum
Buttock
Hip
Back of the thigh
Leg and foot or the SI joint.
PIRIFORMIS SYNDROME
Symptoms
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Swelling can occur in the painful leg and
sexual dysfunction can occur.
Sitting, getting up, activity or standing
can aggravate the condition.
It can also cause the buttock muscles to
atrophy.
Numbness of the foot and loss of
proprioception can lead to an unstable
walk.
PIRIFORMIS SYNDROME
Assessment
Palpation of trigger points
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Side lie on uninvolved
side
 Flex hips to 90º
 Palpate from the greater
trochanter to the sacrum
 Looking for tenderness or
reproduction of
symptoms
PIRIFORMIS SYNDROME
Assessment
Length test
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Flex knee onto chest
with knee in midline
 Maintain midline
position and pull
lower leg across
midline
 Can add hip hitch to
increase stretch
PIRIFORMIS SYNDROME
Assessment
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SLR with resisted external rotation
(below 60º SLR)
SLR with resisted internal rotation
(above 60º SLR)
TREATMENT
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Muscle Energy Techniques
Mobilisation
Manipulation
Core stability exercises
SI belt bracing
Sclerosing injection
Corticosteroid injection
Orthotics
Surgery to fuse the joint
ADVICE
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Pillow between knees in side lie
Pillow under knees in supine
Keep knees together in / out car
Gluts contraction
Avoid asymmetrical positions e.g.
sitting cross legged, standing with
more weight through one leg
ANY QUESTIONS?