* Please Note: The following article is provided by Body Mechanics & Gainesville PT for the sole purpose of educating and informing our current and future patients.

Magazine: Today in PT
April 2, 2007

Section: Sports & Orthopedics
A Solid Base of Support
A look at SI joint dysfunction

By Melissa Gaskill


Millions of people experience lower back pain. According to the World Health Organization, which launched the Bone and Joint Decade in the year 2000, back pain is the second leading cause of work sick leave, and is one of the leading causes of occupational disability. While there are different causes of lower back pain, a major one, according to some physical therapists, is sacroiliac (SI) joint dysfunction.

Vicki Sims, PT, CHT, of Gainesville Physical Therapy in Gainesville, Ga., says, "Ten years ago there were those who didn't think this was a source of low back pain. Some medical professionals are taught that this joint does not move and therefore can't cause pain. But hundreds of articles have been written documenting that the SI joint does move and is a source of pain."

Controversy surrounded the diagnosis for a number of reasons, says Heidi Prather, DO, associate professor, chief of section, physical medicine and rehabilitation, Washington University School of Medicine, St. Louis, and a member of the board of directors of the North American Spine Society. Those include the fact that there is little movement in the joint in young adults and the amount of movement further decreases with aging, and the biomechanics of the SI joint and its interactions with surrounding joints are complex. Additionally, no specific historical point or clinical exam technique will solidify the diagnosis. "Historically, the diagnosis of posterior pelvic pain was based on suggestive history and poorly-validated physical exam findings," Prather says, "so arriving at the diagnosis and prescribing treatment can be difficult. Pain coming from the SI joint is not confined to originate from only the joint; it can comprise both intra- and extra-articular structures."


Causes and symptoms
SI joint dysfunction is basically the result of injury, Sims says. "The ligament complex is torn or stretched, destabilizing the joint and causing it to come out of correct alignment. A stable joint is critical for normal transfer of force from the trunk to the legs, so this leads to pain and problems."

Injuries leading to this problem include acute sprain or strain, either secondary to a fall or from lifting with rotation from a flexed position, or motor vehicle accidents causing forceful extension of the leg, which forces the pelvis into end range, Sims says. "You can also have a chronic sprain or strain, which can be from repetitive lifting, stair climbing, or even a golf club swing." Hormonal changes during pregnancy relax ligaments and can ease the joint out of position. Other causes are muscle imbalances such as muscle spasm due to a disk problem, dysfunction in the kinetic chain such as a shorter leg, abnormal gait due to a limb injury, vertebral movement dysfunction, restricted hip motion, or abnormal foot biomechanics, which can be caused by wearing high heels, she says.

The most common symptoms, Sims notes, are pain in the lower back, buttocks, hips, and groin; urinary frequency; and increased pain with menstruation, sexual intercourse, or stair climbing. But the number one complaint she hears is discomfort from prolonged sitting, standing, walking, or lying down. That, in fact, is one way to distinguish SI joint dysfunction from pain caused by disk-related problems. "SI patients feel like they constantly have to be moving," she says, while those with disk problems can often find a comfortable position if they unload their spines. In addition, SI joint symptoms intensify with activity and decrease with rest, while disk-generated pain can be most severe in the morning.


Diagnostic clues
A diagnosis of SI joint dysfunction hinges primarily on a patient's subjective complaint and a physical evaluation, Sims explains. The exam includes observation of how the pelvis and related structures move relative to one another. Clear understanding of the difference in symptoms of SI dysfunction and other pathologies is key. When a patient presents with low back pain and other common SI joint dysfunction symptoms, Sims looks for anatomical and functional leg length differences; non-equalized right and left pelvic bones, or asymmetry when comparing one side to the other; tenderness to palpation of the posterior SI joint ligaments; pain within range of motion of the hip joint as it stresses the SI joint; and associated muscle guarding in lumbar musculature.

"Imaging is often not helpful," Prather says. "Radiographs, MRI, bone scans, and CT scans do not differentiate symptomatic from asymptomatic patients."

Therefore, Fletcher points out, good evaluation skills are needed to diagnose SI joint dysfunction. "I do a thorough evaluation of the patient's component motion as well as position of pelvis, lumbar spine, and muscle function. It is an involved evaluation. It is important to be able to do an internal muscle assessment as well, and some practitioners don't have that skill." Evaluation methods are addressed, she says, in publications of the Interdisciplinary World Congress on Low Back and Pelvic Pain, which are issued every four years, and in articles by Canadian physiotherapist Diane Lee.

The only reliable objective test is a diagnostic block, or injection of an anesthetic such as lidocaine into the SI joint. If the patient receives temporary relief, it is an indication that the SI joint is the source of the back pain, Fletcher says.


Treatment
A therapist must adequately identify the aggravating factors involved for a particular patient, and help that patient with stabilization devices and techniques to restore all the components that are dysfunctional, Fletcher explains. If a patient has proximal hypomobility, for example, she works on flexibility exercises. If there is inadequate muscle firing, she works on isolating those muscles and strengthening them during activities.

"I often work with patients with pelvic floor dysfunction in conjunction with SI dysfunction, because the pelvic floor is a stabilizer of the SI joint," she says. "Patients with an unstable SI may have a high tone pelvic floor to compensate."

Because the joint is often stretched out of alignment, the goal is to get it back into position, Sims says. "I use manual therapy techniques to mobilize it back into position and teach the patient a self-correcting exercise to return it into position. I usually teach a family member as well." Too much movement of the joint may indicate a laxity of ligaments that normally hold the joint within its normal range of motion, so additional stabilization procedures may be required, such as a pelvic belt fixation or taping techniques. "I put the patient in a pelvic stabilization strengthening or core strengthening program, and include with that a lot of standing motor sensory exercises," she says. "It's basically a six-week program, and 85% of all patients are well at that point and don't need further treatment."

Sims also uses prolotherapy, which involves the injection of an irritant into the attenuated ligaments and tendons to induce an inflammation reaction in the tissues that leads to thickening, which stabilizes the joint. "This leads to natural healing," she says, "and it is a simple and safe office procedure."

Fletcher, however, has not seen patients significantly improve with prolotherapy. "But it takes a lot of skill," she says, "and there are a variety of protocols."

Wider recognition of SI joint dysfunction has been hampered by lack of research, Fletcher says. "Historically, research is funded by pharmaceutical companies. People [in the US] don't get paid to study what is normal biomechanically. But in Europe, especially in the Netherlands, where most of the research came from, practitioners are given money to study this." Patients with SI joint dysfunction won't improve with traditional physical therapy, she adds, because the common exercises for low back pain don't adequately address their issues.

While treatment preferences among therapists vary, most agree that SI joint dysfunction is an important topic, deserving of more attention.


You can view this article on the "Today in PT" magazine website here.