Introduction
The sacroiliac (SI) joint, a pivotal anatomical juncture that unites the spine and pelvis, is indispensable in load distribution and spinal stability. However, dysfunction in this crucial joint often culminates in substantial discomfort and pain, presenting a conundrum for affected individuals and medical professionals. This article delves into the intricacies of SI joint pain, encompassing its underlying anatomy, biomechanics, clinical manifestations, diagnostic methods, and therapeutic alternatives.
Article Index
Introduction
Examination & Diagnosis
Treatment
Exercise
Conclusion & References
Signs and Symptoms
The clinical presentation of SI joint pain and dysfunction is often complex and multifaceted, with patients reporting a variety of pain patterns and characteristics. Commonly reported symptoms include:
Lower back pain
Hip pain
Buttock pain
Pain radiating down the leg, potentially due to the proximity of neural structures to the SI joint or the activation of referral pain patterns[2]
The pain associated with SI joint dysfunction may manifest as:
Sharp sensations, often triggered by mechanical dysfunction during specific movements or positions
Dull or achy sensations, typically resulting from inflammatory processes or chronic dysfunction
Symptoms can be aggravated by activities that load or stress the SI joint, such as:
Sitting
Standing
Walking
Lying down in certain positions
These aggravating factors may be attributed to the increased biomechanical demands placed on the joint and surrounding structures during these activities, exacerbating pain and discomfort. Consequently, SI joint dysfunction can significantly impact an individual's quality of life and functional capacity, warranting thorough evaluation and management within the medical community.
Anatomy and Biomechanics
The sacroiliac (SI) joint is a complex articulation situated at the junction of the sacrum (the triangular bone at the base of the spine) and the ilium (the large, fan-shaped bone of the pelvis) on each side. It is a diarthrodial joint characterized by its unique synovial and fibrous features[1]. The SI joint plays a crucial role in the transmission of forces between the axial skeleton and the lower extremities, as well as contributing to the stability of the pelvis[1].
The SI joint's biomechanical behaviour is influenced by its ligamentous support, consisting of the anterior and posterior sacroiliac ligaments, interosseous sacroiliac ligaments, and the sacrotuberous and sacrospinous ligaments[1]. These ligaments work in tandem to stabilize the joint and limit excessive motion. The surrounding muscles, such as the gluteal muscles, piriformis, and erector spinae, also contribute to SI joint stability and function[2].
Dysfunction of the SI joint can occur due to misalignment, altered biomechanics, or pathology affecting the joint or surrounding structures. These factors may result in abnormal force transmission and movement patterns, leading to pain and discomfort[1].
Kinetic Chains and Fascia: The Interconnected Network
The SI joint is intricately connected to many anatomical structures above and below the joint, contributing to its stability and function. This interconnected network of muscles, ligaments, and fascia, referred to as the kinetic chain, plays a crucial role in maintaining proper biomechanics and force distribution throughout the body.
The kinetic chain comprises of three main components: the pelvis, the lower extremities, and the spine. The pelvis serves as the central hub, connecting the spine and lower extremities, while the SI joint is responsible for transmitting forces between these structures. The surrounding muscles, such as the gluteal muscles, piriformis, iliopsoas, and erector spinae, work together to provide dynamic stability for the SI joint.
Fascia, a continuous network of connective tissue that envelops muscles, bones, organs, and nerves, plays a significant role in the kinetic chain's function. Fascial connections within the lumbopelvic region, such as the thoracolumbar fascia and the iliolumbar ligament, provide additional support and stability to the SI joint. These fascial structures help distribute forces across the lumbopelvic region, reducing stress on individual components and maintaining overall biomechanical balance.
Understanding the interconnected nature of the kinetic chain and fascia is essential in managing SI joint pain. Manual therapy and exercise interventions can help restore optimal SI joint function and alleviate pain by addressing restrictions and imbalances throughout the entire network. A comprehensive treatment approach considers the SI joint and the surrounding structures and their interdependent relationships.
Diagnosis
The diagnostic process for SI joint pain is often intricate, necessitating a comprehensive evaluation of the patient's history, clinical presentation, and a combination of orthopedic, neurological, and vascular examinations[3]. Below are demonstration videos on orthopedic, neurological and vascular tests we often use with SI joint dysfunction.
Low Back Examination - Effective Orthopaedic Testing
This educational YouTube video is an excellent resource for healthcare practitioners, students, and anyone seeking to deepen their understanding of the common causes of low back pain and how to diagnose them using orthopaedic examination procedures.
Lower Limb Neuro Examination
The lower limb neurological examination is part of the overall neurological examination process and is used to assess the motor and sensory neurons which supply the lower limbs. This assessment helps to detect any impairment of the nervous system. It is used both as a screening and an investigative tool.
Peripheral Vascular Examination - Key Points
A peripheral vascular examination is valuable for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. In this video, we review some common procedures we perform in daily clinical practice.
Imaging
Each imaging modality offers unique advantages in the evaluation of SI joint pain and dysfunction, allowing for a more comprehensive understanding of the underlying pathology:
X-rays:
First-line imaging modality for assessing the lumbo-pelvic region
Provides a two-dimensional view of the bony anatomy
Identifies degenerative changes, fractures, or joint malalignment
Assists in ruling out other structural abnormalities in the lumbar spine and pelvis[4]
Magnetic Resonance Imaging (MRI):
Non-invasive imaging technique with detailed visualization of soft tissues and bony structures
Detects inflammatory changes, joint effusion, or bone marrow edema in the SI joint
Identifies lumbar disc herniations, facet joint arthritis, and nerve root compression that may contribute to symptoms[4]
Computed Tomography (CT) scans:
Offers higher resolution images of bony anatomy compared to X-rays
Reveals subtle fractures, joint space abnormalities, or bony erosions
Contributes valuable information about the structural integrity of the SI joint and surrounding osseous structures[4]
Helps rule out other potential sources of pain, such as lumbar spine or hip joint pathology
Differential Diagnosis
The complex nature of pain patterns in the lumbo-pelvic region necessitates a comprehensive differential diagnosis when evaluating SI joint pain and dysfunction. Several conditions can present with similar symptoms, and distinguishing between these conditions is essential for developing an effective and targeted treatment plan. Some conditions to consider in the differential diagnosis include:
Lumbar disc herniation: This condition involves the displacement of the intervertebral disc's nucleus pulposus, leading to nerve root compression and potential radiating pain. Lumbar disc herniation can present with lower back pain and leg pain that may mimic SI joint dysfunction.
Facet joint pain: The facet joints, which connect adjacent vertebrae, can become inflamed or develop arthritis, resulting in localized or referred pain. Pain patterns in facet joint dysfunction can overlap with SI joint pain, and it is essential to differentiate between these two sources of pain.
Hip joint pathology: Conditions such as hip osteoarthritis, labral tears, or femoroacetabular impingement can cause hip and groin pain that may be confused with SI joint dysfunction. A thorough hip joint examination should be performed to rule out hip-related pathology.
Piriformis syndrome: Occurs when the piriformis muscle, located deep in the buttock region, compresses the sciatic nerve. Piriformis syndrome can cause buttock and leg pain similar to that experienced in SI joint dysfunction, making it a relevant differential diagnosis.
Myofascial pain syndrome: Painful trigger points in muscles, such as the gluteal muscles or erector spinae, can cause referred pain patterns that may overlap with SI joint dysfunction. Identifying and addressing these trigger points can help determine whether the pain originates from the SI joint or surrounding musculature.
Sacral stress fractures: Although rare, sacral stress fractures can present with similar pain patterns to SI joint dysfunction. Imaging techniques like MRI or CT scans can help identify stress fractures and rule out SI joint dysfunction.
Treatment
Upon confirmation of the diagnosis, a comprehensive treatment plan incorporating various modalities can be formulated to address SI joint dysfunction. A primary focus is manual therapy and exercise interventions to improve joint mobility, function, and stability.
Manual therapy techniques such as Motion Specific Release (MSR) emphasize the targeted manipulation of soft tissue structures and joint restrictions to enhance SI joint mobility and function[6]. This method can be particularly beneficial for addressing the interconnected nature of the SI joint and the surrounding kinetic chain.
Demonstration Videos
SI Joint Pain - Unravelling the Mystery
The sacroiliac (SI) joint, a pivotal anatomical juncture that unites the spine and pelvis, is indispensable in load distribution and spinal stability. In this video Dr. Abelson DC. and Miki Burton RMT/Instructor demonstrates both effective treatment strategies and some key functional exercises.
Chiropractic Adjustments - Decreased Pain, Better Posture, Improved Function
Spinal manipulation is an essential aspect of musculoskeletal therapy, with a notable impact on force distribution and shock absorption. Facet joints in the vertebrae glide over each other, and when unrestricted, enable efficient force distribution and shock absorption. However, factors such as poor posture, muscle imbalances, or trauma can restrict these joints, limiting their capacity. Spinal manipulation restores joint mobility, thus enabling the spinal column's capacity for force distribution and shock absorption.
Exercise
Functional exercise programs strive to enhance strength and stability of the muscles surrounding the SI joint, thus reducing pain and optimizing overall function. These programs may incorporate the following components:
Mobility exercises: Designed to improve joint range of motion and flexibility, specific exercises may include:
Piriformis stretch: To target the hip rotator muscles
Posterior hip stretch: To address the gluteal and deep hip external rotator muscles
Lumbar spine rotation stretch: To enhance spinal mobility and flexibility
Strengthening exercises: Focused on engaging core, hip, and pelvic muscles, examples of targeted exercises include:
Supine bridge: To activate gluteal and hamstring muscles
Plank variations: To strengthen the core and stabilize the lumbar-pelvic region
Clamshells: To engage the hip abductor and external rotator muscles
Balance and proprioception training: Aimed at improving neuromuscular control and joint stability, these exercises may involve:
Single-leg stance: To challenge balance and stability while engaging hip and core muscles
Bosu ball squats: To develop proprioceptive awareness and lower body strength
Dynamic balance exercises, such as tandem walking or lateral shuffling, to enhance coordination and stability
Exercise Demonstration Video
SI Joint Pain - Unravelling the Mystery
In the later part of this video Miki Burton RMT/Instructor demonstrates effective exercises and some key functional exercises. The time stamp for these exercise is 09:40.
Conclusion
In conclusion, sacroiliac joint pain and dysfunction can present a complex and challenging issue for both medical practitioners and patients alike. By delving into the intricate anatomy and biomechanics of the SI joint, understanding the signs and symptoms, and employing a thorough diagnostic process, practitioners can effectively identify the underlying issues and formulate appropriate treatment plans.
A multifaceted approach, combining manual therapy techniques such as Motion Specific Release, functional exercise programs targeting mobility, strength, and proprioception, and complementary treatments, can yield significant improvements in pain relief and overall function. As we continue to expand our knowledge of the SI joint and its role in the kinetic chain, we can better equip ourselves to manage this prevalent and often debilitating condition, ultimately enhancing the quality of life for those affected.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
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References
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Cohen, S. P. (2005). Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesthesia & Analgesia, 101(5), 1440-1453.
Laslett, M. (2008). Evidence-based diagnosis and treatment of the painful sacroiliac joint. Journal of Manual & Manipulative Therapy, 16(3), 142-152.
Slipman, C. W., Jackson, H. B., Lipetz, J. S., Chan, K. T., & Lenrow, D. A. (2000). Sacroiliac joint pain referral zones. Archives of Physical Medicine and Rehabilitation, 81(3), 334-338.
Hansen, H., Manchikanti, L., Simopoulos, T. T., Christo, P. J., Gupta, S., Smith, H. S., ... & Hameed, H. (2012). A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician, 15(3), E247-E278.
Abbey, B., & Abbey, M. (2021). Motion Specific Release: A Comprehensive Manual Therapy Approach. Kinetic Health.
Cher, D. J., & Polly, D. W. (2016). Re: Cher DJ, Reckling WC, Capobianco RA, et al. Implant survivorship analysis after minimally invasive sacroiliac joint fusion using the iFuse Implant System. Medical Devices: Evidence and Research. 2015;8: 485–492. Medical Devices: Evidence and Research, 9, 79-80.
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Kurosawa, D., Murakami, E., & Aizawa, T. (2015). Sensory nerve fibres from lumbar intervertebral discs pass through rami communicantes: a possible pathway for discogenic low back pain. Journal of Bone and Joint Surgery. British Volume, 87(10), 1391-1394.
Maigne, J. Y., Aivaliklis, A., & Pfefer, F. (1996). Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine, 21(16), 1889-1892.
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O'Sullivan, P. B., Phyty, G. D., Twomey, L. T., & Allison, G. T. (1997). Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine, 22(24), 2959-2967.
Shum, G. L., Crosbie, J., & Lee, R. Y. (2005). Symptomatic and asymptomatic movement coordination of the lumbar spine and hip during an everyday activity. Spine, 30(23), E697-E702.
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