Sacro-Iliac Joint Dysfunction
SI dysfunction is very often neglected. Dr. Cyriax states that due to lack of movement, no intra-articular meniscus and no muscle spanning the joint… “All in all, there is little that can go wrong”. McKenzie for instance categorizes SI as miscellaneous 15% source of back pain other than derangement, posture, and dysfunction syndromes. Personally, I agree with Maitland’s point of view regarding this area, who states: “The main reason for confusion lies in the fact that the physical examination tests for SI joint, in fact move many other joints, at the same time.” The point he is trying to get across is that we have to be open minded during the process of examination. We have to be sure of what we are testing and from where we are receiving response.
Due to the smaller possibility of SI joint dysfunction and similar manifestation of the symptoms to lumbar, hip, or buttock problems, first I would rule out the lumbar spine, than I would go through some tests presented below to distinguish this from buttock or hip involvement. Initially to build your hypothesis always start by carefully listening to the patient’s subjective statement.
Pain associated with SI joint dysfunction can be: in the buttock, deep in the pelvis, in the hip, in the groin, on the back of the thigh, and can radiates down the leg to below knee level.
Other presentations are:
· Negative dural sign
· Onset associate with traumatic nature (for example: Motor Vehicle Accidents that involves straight leg on brake pedal) is more likely a unilateral problem associated with asymmetry
· Onset associated with pregnancy is more likely bilateral associated instability and hormone related changes
· Patient’s c/o slipping, giving away
Now we can go to objective measurements and confirm or deny our initial hypothesis. I share the same opinion of those therapists who don’t believe that asymmetry as well as therapist observation and palpation can be reliable factors for determining of SI dysfunction. Let’s check some other more reliable objectives, which can help us to distinguish SI. They are:
Due to the smaller possibility of SI joint dysfunction and similar manifestation of the symptoms to lumbar, hip, or buttock problems, first I would rule out the lumbar spine, than I would go through some tests presented below to distinguish this from buttock or hip involvement. Initially to build your hypothesis always start by carefully listening to the patient’s subjective statement.
Pain associated with SI joint dysfunction can be: in the buttock, deep in the pelvis, in the hip, in the groin, on the back of the thigh, and can radiates down the leg to below knee level.
Other presentations are:
· Negative dural sign
· Onset associate with traumatic nature (for example: Motor Vehicle Accidents that involves straight leg on brake pedal) is more likely a unilateral problem associated with asymmetry
· Onset associated with pregnancy is more likely bilateral associated instability and hormone related changes
· Patient’s c/o slipping, giving away
Now we can go to objective measurements and confirm or deny our initial hypothesis. I share the same opinion of those therapists who don’t believe that asymmetry as well as therapist observation and palpation can be reliable factors for determining of SI dysfunction. Let’s check some other more reliable objectives, which can help us to distinguish SI. They are:
- Positive Modified Straight Leg Raise Test
- Positive FABER Test
- Positive three out of five pain provocative test
2. Thigh Thrust Test
3. Sacral Spring Test
4. Distraction Test
5. Compression Test
- Long Leg Sit Test (less reliable than others, but helps me with assessment of the innominate bone rotation over the sacrum)
Finally, we will conclude with treatment. If the results of the intervention are poor I would recommend reassessing our findings. If your conclusion from the initial evaluation was right, results of treatment should begin immediately. I won’t say the patient will be healed in one session but the patient should report a change in status. Don’t be scared if the patient reports irritation of symptoms, it means you touched the problem, but the technique requires correction. If you know why and what you have done you will be able to correct your approach.
Some tips regarding intervention:
· Reassess the patient after each technique
· Start with minimal force
· If progress was noticed continue until you reach a plateau in progress
· If you reach a plateau, increase force then reassess
· If you reach a plateau again, move to another technique
· If symptoms cause irritation, decrease force
· If symptoms get worse try a different direction
· Don’t continue if your technique causes irritation, or makes the patient worse
· Listen to and observe the patient through the whole treatment
· Ask the patient if you do not get a response to your approach
· Build confidence to your approach
· Posterior rotation of the innominate was my most often used successful technique (meaning most of my patients more likely had anterior rotated dysfunction)
If your intervention was just a guess, or part of a routine, you better have a good guess otherwise you are in a deep, dark forest.
Some tips regarding intervention:
· Reassess the patient after each technique
· Start with minimal force
· If progress was noticed continue until you reach a plateau in progress
· If you reach a plateau, increase force then reassess
· If you reach a plateau again, move to another technique
· If symptoms cause irritation, decrease force
· If symptoms get worse try a different direction
· Don’t continue if your technique causes irritation, or makes the patient worse
· Listen to and observe the patient through the whole treatment
· Ask the patient if you do not get a response to your approach
· Build confidence to your approach
· Posterior rotation of the innominate was my most often used successful technique (meaning most of my patients more likely had anterior rotated dysfunction)
If your intervention was just a guess, or part of a routine, you better have a good guess otherwise you are in a deep, dark forest.