SI Joint Eval & Tx

Question 1

SI Joint

2 Components

Answer 1

1. Ilium
2. Sacrum

Question 2

Long standing controversy regarding Role of SIJ in LBP:

2 Extreme Views

Answer 2

1. Largely dismissed functionally 2* to little or no mvmt
2. Has important primary mvmts that can be assesed as other jts

Question 3

SIJ

FACTS:

Answer 3

• Cannot be considered as any other jt in body
  
  • ​mvmts= small
  • not endowed w/ muscles that execute active mvmts
• Structurally and functionally more comparable to intertarsal jts of foot
• Needs to be both stable and mobile
• Motion occurs via action of mm’s moving adjacent bony structures AND GRF’s

Question 4

2 Unique Roles of the Sacrum

Directions?

2:

Answer 4

1. Longitudinally
2. Transversely

Question 5

2 Unique Roles of the Sacrum

1. Longitudinally

Answer 5

• Supports L/S, all long. forces delivered to L/S transmitted to sacrum

Question 6

2 Unique Roles of the Sacrum

2. Transversely

Answer 6

• Consitutes post. wall of the pelvis, transmits forces sideways from the VC into the pelvis and vice versa

Question 7

SIJ as a Functional Unit

Answer 7

• L5-S1
• SI jts (L and R)
• Symphysis Pubis
• Bones: 2 Innominates; Sacrum

Question 8

Architecture/Morphology of SIJ

Answer 8

• Part synovial, part syndesmosis
• Sacral surface cartilage→ largely hyaline, 2-3x thicker than iliac
• Iliac surface cartilage→ mix of mostly hyaline w/ fibrocart.
• Surfs irregular→ vary in lvl congruency
• Bonnaire’s Tubercle→ on iliac surf of SIJ b/w upper and lower aspects
  
  • pivot point for Nutation/Counternutation
• Sacrum wider dorsally at S1 and wider ventrally @ S3

Question 9

Nutation

Answer 9

Occurs as sacrum moves anteriorly and inferiorly while the coccyx moves POST relative to ilium

*coccyx pulled UP

Think “cocking it into place pulling coccyx up”

Question 10

Counternutation

Answer 10

Occurs as sacrum moves POST and SUP while the coccyx moves ANT relative to ilium

“pushing Coccxy IN”

Question 11

Nutation/Counternutation Ex.

Answer 11

WALKING!

*may be some degree of nutation on one side and counternutation on the other side

Question 12

SIJ

Ligs/Joint Cap

Interosseus Ligament

Answer 12

• MOST IMPORTANT ligament of the SIJ
• Lies deep in the narrow recess b/w sacrum and ilium, dorsal to joint cavity
• Functions to strongly bind sacrum TO ilium

Question 13

SIJ Ligs

Post. SI Ligament

Answer 13

• Connects intermed and lateral crests of sacrum TO PSIS and post end of inner lip of iliac crest
• Acts in concert w/ interosseus lig to bind sacrum to ilium
• Mostly prevents post flaring or diastasis of the joint
• Longer fibers of lig prevent backward rocking (counternutation) of sacrum

Question 14

SIJ Ligs

Anterior Sacroiliac Lig

Answer 14

• Covers ventral (FRONT) aspect of joint
• Transverse fibers running from ala (wings) and ant surf of sacrum to the ant surf of ilium
• Attach’s are of considerable dist beyond the margins of the joint
• encompasses the ant. cap of SIJ
• Binds ilium to sacrum
• Prevents ANT diastasis (flairing) of joint (nutation)

Question 15

Sacrospinous Ligament

Answer 15

• “sacro”-sacrum TO “spinous”- ischial spine
• broad orig. from the lat edge BELOW SIJ converging on the ischial spine
• Prevents nutation (forward rocking of sacrum) → remember think cocking coccyx BACK

Question 16

Sacrotuberous ligament

Answer 16

• Orig’s from multiple points on sacrum:
  
  • PSIS
  • Transv tubercles of lower sacral segs
  • Inf Lat. margin on sacrum
  • Broad attach to medial margin of isch tuberosity
• Superf fibers of lig are cont w/ long head of biceps fem tendon
• Prevents nutation of sacrum

Question 17

MM’s affecting SIJ

Answer 17

QL

Multifidi and Erectors→ contraction produces nutation of sacrum

Psoas

Iliacus

Glute max

Biceps fem

Rec fem

Adductors

Hip rotators

TA

coccygeus (pelvic floor mm’s)

Question 18

Jt mechs of SIJ

Answer 18

• Bony locking mech prevents downward motion of sacrum under BW
• Sacrum set obliquely b/w ilia→ SUP end leans ventrally
• Under vertical loads it tilts forward and downward→ nutates (forward rock) around Bonnaire’s Tub
• Shape of sacrum gives bony opposition to nutation
• Ligs keep mvmts minimal****

Question 19

SIJ Changes across lifespan

Answer 19

• 0-10→ highly mobile, jt plane close to vertical
• 10-30→ jt plane becomes oblique
• 40→ osteophytes form, capsule thickens, DJD
• 50-60→ motion DECs
• 60-80→ ankylosis (fusing)

Question 20

Prevalence SIJ Disorders

Answer 20

~15% of pts w/ chronic LBP

Question 21

SIJ Disorders

Gender Diffs

Answer 21

• Pregnancy→ hypERmobile (Relaxin hormone)
• More accel’d ankylosis in males
• Female SIJ smaller, flatter=> more mobile
• COG and SIJ: Females
  
  • SAME frontal plane
• COG and SIJ: Males
  
  • COG more ventral

Question 22

Diff Dx SIJ

Answer 22

Validity of many mech tests questionable

Sx distribution is poor indicator BUT pts w/ SIJ probs typ have no pain above waist

Question 23

Possible historical and Dx Clues for SIJ patho

Answer 23

• Trauma→ long axis force thru femur OR direct fall on one isch tub (miss chair)
• Inj inolving twist or asymm motions
• pain rolling side to side
• pain ascend/descend stairs
• WB acts may be provocative
• pregnancy/post-partum
• pain w/ arising from seated pos
• absence of midline lumbar pain w/ buttock pain

Question 24

EXAM for SIJ

clear lumbar spine and hip first

HOW?

Answer 24

LOOK @ ALL OTHER SUBGROUPS FIRST:

• Manip?
• Directional pref?
• Instability?
• THEN SI

Question 25

3 tests you should do for SI FIRST!!!

Answer 25

1. SI Compress/Distract 2. Sacral Thrust 3. Thigh Thrust

Question 26

International Ass. for the Study of Pain Dx criteria for Symptomatic SIJ

Answer 26

* Pain present in area of SIJ * Selective stressing of SIJ by clin provocation that repros pain * **selective infiltration of the symptomatic SIJ w/ anesthetic completely relieves pain**

Question 27

**Special Tests for SIJ:** **PROVOCATION TESTS** **\***Highest **reliability and validity**

Answer 27

* Laslett found these 4 contributed to making dx of SIJ pain and dysf * Robinson found **reliability** of **pain prov** tests was mod to good while **reliability of palp was poor**

Question 28

**Special Tests for SIJ:** **PROVOCATION TESTS** **4:**

Answer 28

1. SI Distraction 2. Thigh Thrust 3. SI Compression 4. Sacral Thrust

Question 29

**Special Tests for SIJ:** **PROVOCATION TESTS** **SI Distraction Test**

Answer 29

see pics

Question 30

**Special Tests for SIJ:** **PROVOCATION TESTS** **Thigh Thrust**

Answer 30

see pics

Question 31

**Special Tests for SIJ:** **PROVOCATION TESTS** **SI Compression Test**

Answer 31

see pics

Question 32

**Special Tests for SIJ:** **PROVOCATION TESTS** **Sacral Thrust**

Answer 32

see pics

Question 33

**Laslett's _Clinical Dx Rule_ for SIJ** **\***Perform **SI Distraction** and **Thigh Thrust tests _FIRST_!!! \*\*\*\***

Answer 33

* Inclusion vs. exclusion **Gaenslen's test did not sig. alter results** * \*When **all provocation SIJ tests are _NEGATIVE→_ SIJ Patho can be R/O** * Thigh Thrust→ greatest Sn→ .88 (SnNOUT) * Distraction→ greatest Sp→ .81 (SpPIN) * OPTIMUM RULE: * **perform _distraction_ and _thigh thrust_ FIRST** **\*NOTE: if _familiar sx's_ not provoked→** cont. w/ remaining tests until a **total of 2 positives found**

Question 34

Special Tests of SIJ: **Mobility/Palpation/Pos Tests** ## Footnote **What should you know about these?**

Answer 34

In general, _poor reliability and validity_\*\*\*

Question 35

Special Tests of SIJ: **Mobility/Palpation/Pos Tests** _Support Side_ Stork Test (\*Stork think standing on one leg like a stork\*\*\*\*)

Answer 35

see pics **\*NOTE:** relative to other mobility/palpation/pos tests→ **this one had GOOD reliability found w/ _stork test on the support side_**

Question 36

Special Tests of SIJ: **Mobility/Palpation/Pos Tests** Support Side Stork Test

Answer 36

* **Negative Test:** innominate rotation **POSTERIORLY** (moves caudal) on the **support side** relative to the sacrum OR _stayed relatively neutral_ * \*this test assesses the joint in a _loaded pos._ to det normal stability * **POSITIVE Test:** innominate rotation **SUPERIORLY** (moves cephalad) on **support side** relative to sacrum * **Interpretation:** indicates _failure of_ **_self-bracing mech._** to maint. SIJ in ints closed pack pos. * i.e.→ POSITIVE test is suggestive of **SIJ instability or hypermobility on the stance leg**

Question 37

Special Tests of SIJ: **Mobility/Palpation/Pos Tests** **Gilet's (Sacral Fixation) Test** **\***almost same as stork test **but now you palpate PSIS on hip that is flexing up (non-supported side)**

Answer 37

Almost same as **Stork Test,** but palpate PSIS on **same side as the hip that pt is flexing** Thus, in this case you are assessing **unloaded (NWB) side**

Question 38

Special Tests of SIJ: **Mobility/Palpation/Pos Tests** ## Footnote **Seated Flexion Test (Piedallu's Sign)**

Answer 38

* Are PSIS lvl @ start w/ pt seated? * Do they remain lvl as pt flexes forward? * **IF NOT→** indicative of SI jt imbalanace OR perhaps hypOmobility on 1 side * \***Magee's Interpretation:** if one PSIS is LOWER in upright sitting then appears HIGHER after forward bend→ **that side is hypOmobile**

Question 39

Gaenslen's Test SEE LAB NOTES!!!!!

Answer 39

SEE PICS

Question 40

Special Tests of SIJ: **Mobility/Palpation/Pos Tests** ## Footnote **Supine-to-Sit Test** **\*MAKE SURE YOU HAVE THEM DO A BRIDGE FIRST TO SET THE PELVIS**

Answer 40

* **Interpretation:** * If leg on PFL side appears **LONGER in supine** and then **SHORTER in long-sitting→** Innominate on that side= **Anteriorly rotated\*\*\*** * If leg on PFL side appears **SHORTER in supine** and then **LONGER in long-sitting→** Innominate on that side=**Posteriorly rotated\*\*\***

Question 41

Special Tests of SIJ: **Mobility/Palpation/Pos Tests** ## Footnote **Palpation of PSIS, ASIS, Iliac Crest Hts**

Answer 41

* **Interpretation of findings on PFL Side:** * **PSIS HIGHER, Iliac crest HIGHER, ASIS LOWER=\>** ANT rotated innominate on PFL side * **PSIS LOWER, ASIS HIGHER=\>** POST rotated innominate on PFL side ***NOTE:** _Pelvic Asymmetry_: No meaningful assoc. w/ back pain\*\*\**

Question 42

**Interventions for SIJ Dysf.** **Directional Preference Ex.** **\*if they have one…**

Answer 42

* Force transmitted to the SIJ via **trunk or LE motions** * Hip flex vs. hip ext. * **Lunges w/ R vs. L LE ant (in front, like a split lunge)** * May have to alter **hip IR or ER**

Question 43

**Interventions for SIJ Dysf.** **Muscle Energy Techniques\*\*\*\*** ***First determine direction of innominate rotation*** Anteriorly Rotated Innom.

Answer 43

* **IF proble is _ANTERIORLY rotated innominate:_** * GOAL= correct it by POSTERIORLY rotating it * SKTC on affected side * foot UP on table/chair (affected side foot UP) * lunging w/ involved side forward * **MM Energy Techs** using the **hip ext's→** ISO. contraction of hip ext's generates POST ROT. moment on innominate * bc EXT's pull pelvis POST * \***majority of pts w/ SIJ probs respond to tx involving _post rotation forces on innominate_**

Question 44

**Interventions for SIJ Dysf.** **Muscle Energy Techniques\*\*\*\*** ***First determine direction of innominate rotation*** Posteriorly Rotated Innominate

Answer 44

* **IF problem is a _POSTERIORLY Rotated Innominate:_** * GOAL= correct it by _ANTERIORLY rotating innominate_ * Stretching into HIP EXT (on affected side) * Lunging w/ **involved side BACK** * **MM Energy Techs→ ISO. contraction of HIP FLEXORS** * ISO contract of hip flexors generates ANT. ROT. moment on innominate * bc these mm's pull pelvis ANTERIORLY

Question 45

**Interventions for SIJ Dysf.** **Muscle Energy Techniques\*\*\*\*** ***First determine direction of innominate rotation*** ***3 other ways if its _both sides rotated diff directions_***

Answer 45

1. Ant/Post rotation via **resisted hip flex/ext in _hooklying_** 2. End range Ant/Post rotation via **resisted hip flex/ext** 3. **Pubic Shotgun** 1. pt in **hooklying** 2. PT briefly and firmly resists hip ABD (B/L) 3x 1. 1st w/ knees close together 2. 2nd w/ knees slight apart 3. 3rd knees more wide apart 3. NEXT.. PT repos's hands to **resist ADD (B/L) of hips** 1. as pt ADD's, PT pushes OUTWARDLY into ABD w/ a **quick thrust** 2. **\*\*\* SEE LAB NOTES!!!**

Question 46

Special Tests of SIJ: **Mobility/Palpation/Pos Tests** ## Footnote **Gentle Mob. Tech's aka Iliac Rocking**

Answer 46

1. **STM→** Sacrotuberous lig 1. palp **inf lat angle of sacrum** off the **coccyx** and the **isch tub- lig is ½ way b/w these two** 2. **mobilize into rolling motion about 1min** 2. **Stab. Belts** 3. **Lumbopelvic Stab. Ex Program** 1. TA, Pelvic Floor 2. \***we want them to work in the “new corrected" pos.** 4. Bridging w/ _alternating_ **hip ADD or ABD stab. ex.**

Question 47

In general ## Footnote **If innominate is ANT ROTATED…**

Answer 47

You want to STRETCH the Hip EXT's OR ISO contraction of HIP EXTs

Question 48

In General, ## Footnote **If Innominate is POSTERIORLY ROTATED**

Answer 48

You want to STRETCH hip flexors OR ISO contraction of Hip flexors