Sacroiliac Joint Syndrome
Erik Dalton, Ph.D.
Article as seen in Massage Today Magazine February 2007
| In the early 20th
century, sacroiliac joint syndrome was the most common medical
diagnosis for low back pain, which resulted in that period being
labeled the “Era of the SI Joint.” Any pain emanating from the
low back, buttock or adjacent leg usually was branded and
treated as SI joint syndrome. However, this medical mindset came
to a screeching halt in 1934, when Jason Mixter, MD, published
an article on the intervertebral disc lesion in The New
England Journal of Medicine.1 His landmark
report changed the popular understanding of sciatica and helped
establish surgery’s prominent role in the management of sciatica
at the time. Over the next few decades, discectomy surgery
increased in popularity, causing many to define that period as
the “Dynasty of the Disc.” |
Figure 1 |
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Figure 2 |
SI joint syndrome
continued its fall from fashion due to the lack of reliable
clinical studies confirming its very existence. Although many
manual therapists quietly continued treating this disorder with
some success, no one was able to put forward a convincing
biomechanical theory explaining how the sacrum becomes stuck
“crooked” between the two innominate bones. Physicians were
hesitant and reluctant to envision a joint with so little
movement causing so much pain, while manual therapists countered
that its limited motion is vital to proper lumbar spine
functioning. So, the SI joint controversy raged until the late
1970s, when renowned manipulative osteopath Fred Mitchell Sr.
introduced an innovative and practical biomechanical model that
clearly demonstrated normal and aberrant SI joint movement
patterns occurring in most individuals.2 Using
muscles as levers to correct lumbopelvic restrictions,
Mitchell’s muscle energy technique spurred a renewed interest in
the SI joint as a source of back pain. Figure 1
and Figure 2 demonstrate a modified
muscle-energy assessment and correction routine for a painful
left unilateral extended sacrum. |
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| Since
most SI joints only move about 2 to 4 millimeters during weight
bearing and forward bending, they are described as a
gliding-type joint. This motion is quite different from the
hinge-type articulation at the knee or the ball-and-socket
motion of the hip. Considered a viscoelastic joint, the SI’s
major movement comes from ligamentous stretching. Therefore, its
primary function within the pelvic girdle is to provide shock
absorption for the spine by stretching in various directions.
When sacroiliac joints work in perfect harmony with the third
bony articulation of the pelvis (symphysis pubis), a marvelous
self-locking mechanism develops that helps us walk. Aided by
power generated by the hip abductors (gluteus medius/ minimus,
TFL and piriformis), the pelvic joints brace the weight-bearing
side during gait. This locking system, termed force closure,
allows smooth transference of body mass from one leg to the
other (Fig. 3). Although no muscles directly
bind down the three pelvic joints, when working synchronously
with the SI ligaments they provide the pelvis − “the great
adapter” − with a remarkable antigravity springing system that
can absorb both ascending and descending forces (Fig. 4). |
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During the aging
process, there is an increase in the grooves on the opposing
surfaces of the sacrum and ilium, which reduces available motion
of the SI joint. This is a perfect example of the body’s innate
wisdom attempting to sacrifice complexity of motion for
stability. An interesting note is that the age with
highest incidence of disabling back pain (25-45 years) is the
same age at which the greatest amount of motion is available in
the sacroiliac joints. It’s not uncommon for an SI joint to
become stiff and permanently lock as we age. This may be a good
reason for massage therapists to begin incorporating specialized
soft-tissue mobilization techniques on a regular basis, to
maintain joint-play and prevent agonizing arthrosis and
arthritis from developing. Due to the small amount of sacroiliac
movement and the joint’s inherent biomechanical complexity,
proper assessment can be tricky. |
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| Frequently, muscle imbalance patterns
develop as tissues become strained from overuse, underuse or abuse.
In the early stages of a typical SI pain episode, protective muscle
spasm arises as the sacrum gets stuck side-bent and rotated between
the ilia, usually from a forward-bending and twisting incident (Fig.
5).
Sustained isometric contraction produces
muscle toxicity and weakness causing increased SI ligament loading
and overstretching. As the articulating joint surfaces become jarred
loose, ligament microtearing creates an inflammatory response.
Sensitive chemoreceptors bombard the spinal cord and brain with
noxious stimuli, causing the brain to layer the area with protective
muscle guarding. This is the beginning of a therapeutically
challenging pain/spasm/pain cycle that often is hard to break. It’s
possible, however, to eliminate pain emanating from hypermobile
joints by restoring proper pelvic alignment, frictioning the loose
ligaments and addressing core strengthening exercises. |
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Although the three
bones of the pelvis frequently are at the seat of a “primary”
lesion, I have found that a missing key in successful correction
of recurrent SI pain is motion-restricted hip joints, i.e., poor
alignment of the femur in the acetabulum. For the pelvis to
effectively absorb the forces imposed upon it, the hips must be
aligned and functioning properly. Normally, it’s not the gross
motions creating dysfunction within the hip’s truncated joint
capsule, but restrictions of minor movements such as iliofemoral
ligament adhesions (Fig. 6). Therefore, a
rational treatment approach would begin with mobilization of the
adhesive hip capsule, followed by step-by-step restoration of
iliosacral alignment (movement of ilia on sacrum) and sacroiliac
alignment (movement of sacrum between the two ilia). |
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| Vladimir Janda, MD,
reminds us that: “Any alteration in joint function caused by
capsular restriction or loss of joint play affect muscles that
cross the dysfunctional joint either through inhibition
(weakening) or facilitation (tightening).”2,3
Following this line of thought, a fibrosed hip capsule (usually
right) could reflexively spasm and shorten the neighboring
iliopsoas muscle, causing reciprocal weakness in its antagonist
gluteus maximus. This commonly seen muscle imbalance pattern
produces a right anterior inferior rotated (AIR) ilium that
refuses to stay aligned no matter how much “psoas-beating” the
therapist performs (Fig. 7). Many in today’s
flexion-addicted society suffer from anterior hip capsule
adhesions and tight psoas muscles that “glue” the femur into a
flexed position, preventing adequate hip extension during gait.
But we have to walk … so what happens? As the right leg swings
back into extension, the short iliopsoas and fibrosed hip
capsule drag the already anteriorly rotated right ilium more
forward and down, causing increased lumbosacral angle, facet
joint and disc compression, greater ligament laxity,
compensatory lumbar scoliosis and pain (Fig. 8). |
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Figures 9-11
demonstrate a nice pelvic balancing routine I’ve found effective
for releasing adhesive hip capsules, lengthening iliopsoas and
correcting iliosacral alignment. Competing athletes suffering
recurring unilateral hamstring pulls always should be evaluated
for hip capsule restrictions that might be causing iliopsoas
facilitation and glute max inhibition. The most common cause of
persistent hamstring injuries results from an altered firing
order pattern, whereby a weak gluteus maximus fires late during
hip extension, forcing the hamstrings to do all the work. Since
motion-restricted joints can reflexively weaken associated
muscles, it’s a good idea to mobilize all capsular restrictions
and lengthen tight postural muscles before attempting to
strengthen muscle groups perceived as weak. |
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Figure 9 |
Figure 10 |
Figure 10 |
Once optimal hip range of motion and
iliosacral alignment are restored, sacroiliac problems often
spontaneously correct themselves … but not always. If low back,
buttock or leg pain persists, the therapist must be equipped with
proper assessment and treatment tools to effectively deal with SI
joint syndrome. Of the 10 or so ways the sacrum can become stuck
crooked between the two ilia bones, usually only the flexed,
extended and torsioned sacroiliac dysfunctions prove to be
pain-generators. In the next “Toolbox of Touch” column, I will
discuss and demonstrate six useful deep-tissue myoskeletal
techniques for assessing and correcting sciatic symptoms caused by
backward sacral torsions and lumbar scoliosis.
References
- Parisien
RC, Ball PA. William Jason Mixter (1880-1958). Ushering in the
“dynasty of the disc.” Spine Nov. 1998;23(21):2363-6.
- Mitchell F. An Evaluation and
Treatment Manual of Osteopathic Muscle Energy Techniques.
Institute for Continuing Education in Osteopathic Principles,
1979.
- Janda V. Treatment of chronic back
pain. Journal of Manual Medicine 1992;6:166-8.
- Warmerdam A. “Arthrokinetic
Therapy: Improving Muscle Performance Through Joint Mobilization.”
Class notes from International Federation of Orthopaedic
Manipulative Therapists, Vail, Colo., 1992.
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