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Vicki Sims, PT, CHT
Gainesville Physical Therapy
1296 Sims Street, Suite A
Gainesville, GA 30501
Phone: 770.297.1700
sijd@gainesvillept.com
www.gainesvillept.com

David Mesnick, PT, cMDT
Atlanta Falcons Physical Therapy Center
550 Peachtree Street, Suite 1760
Atlanta, Georgia 30308
Phone: 404.367.2095
dmesnick@afptc.com
www.atlantafalconsptc.com
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GENERAL INFORMATION, ANATOMY & TREATMENT

 




Anatomy

Thumbnail image The sacrum (tailbone) connects on each side to the ilia (pelvic bones) to form the sacroiliac joints.

The pelvic girdle consists of two innominate bones (the iliac bones) and the sacrum. The innominate bones come together in the front to form the pubis symphysis (a secondary cartilaginous joint) and with the sacrum in the back to form the sacroiliac (SI) joints. For more information on Sacroiliac Joint Dysfunction please click here.

Each innominate bone (ilium) joins the femur (thigh bone) to form the hip joint. As a person walks or moves the torso and sacroiliac joints also moves.

Muscles and ligaments surround and attach to the SI joint in the front and back. These can all be the source of pain and inflammation if the SI joint is dysfunctional. Much of the integrity of the sacroiliac joint depends on its ligamentous structure. The most commonly disrupted and/or torn ligaments are the iliolumbar ligament and the posterior sacroiliac ligament. For a free self-evaluation please click here.

The muscular attachment of the pelvic girdle is very extensive. Many of the muscles directly influence sacroiliac motion. The primary muscles involved are:
The gluteus maximus is a massive structure mainly responsible for extension of the hip joint. The pull of the gluteus maximus on the sacrotuberous ligament is thought to produce enough tension to counteract forward flexion of the sacrum on the ilia (Vleeming et al., 1989). Its direct attachment to the sacrum may influence the stability of the joint.

The gluteus medius and minimus act to abduct the hip joint. If the femur is fixed, these muscles are believed to separate the ilia from the sacrum.

Biceps femoris is a hamstring muscle that flexes the knee and extends the hip. The long head of the muscle originates from the ischial tuberosity. The muscle may also partly originate from the sacrotuberous ligament (Vleeming et al., 1989). Like the piriformis and gluteus maximus, this muscle has an ancillary function of stabilizing the sacroiliac joint via the sacrotuberous ligament, primarily stabilizing against forward flexion of the sacrum on the ilia.

The iliopsoas muscle runs across the front of the hip joint immediately in front of the femoral head. Its action is to flex the hip and contributes to the stability of the hip during walking and standing. It can also be a source of groin pain in the presence of a sacroiliac joint dysfunction.

The piriformis muscle, like the gluteus maximus, originates from the sacrotuberous ligament (Vleeming et al., 1989). It runs from the front of the sacrum to the femur and its action is to outwardly rotate the femur. It is a stabilizer of the SI joint via the sacrotuberous ligament. It is often the source of deep buttock pain associated with a sacroiliac dysfunction.

The quadratus lumborum is a rectangular muscle that runs from the 12th rib to the top of the ilium. It can often be a source of side pain in the presence of sacroiliac joint dysfunction.
The sacroiliac joint (SIJ) and its associated ligaments connect the spine to the pelvic girdle. The latter articulates with the hip.

Occasionally, the joint or its ligaments can become strained and cause pain that closely mimics sciatica caused by a lumbar herniated disc. The pain starts in the back and radiates down the leg. It can be felt in the hip region or groin.

It is important to make this distinction because herniated lumbar discs do not always cause pain. In fact, many peoples have herniated discs that have never caused pain and are found when a test is done for some other reason! There is no reason to operate on a disc that is not causing any problem.

Strains of the sacroiliac joint are often due to falls or forceful twisting motions. The pain can be severe! It is usually worse when getting up from a chair or climbing stairs and it is often difficult to find a position of comfort. Urinary frequency may occur in women as well as discomfort with bowel movement and sexual intercourse. The pain can be felt as an ache in the whole leg and might involve both legs.

A herniated disc might occur at the same time (often at the L4-5 level because of a ligament between the vertebra and the SI joint) causing concomitant true sciatica. The herniated disc is usually recognized and surgically treated but the pain does not resolve because of the concomitant sacroiliac strain! This is a scenario that I have encountered many times in clinical practice.

Sacroiliac pain is due to subluxation of the joint. The range of movement is small and therefore cannot be detected on XRs. Sacroiliac dysfunction must be diagnosed by clinical exam.

The two sides are compared for symmetry with the painful side considered the abnormal one. The ilium can be rotated anteriorly or posteriorly. There can be an upslip (the most frequent) or downslip. Often, the sacrum is also rotated, placing strain on the facets (the joints of the spine). Those subluxations can be determined by clinical examination and reduced with various manipulations and exercises.

Some other tests are meant to mobilize the joint and exacerbate the pain to confirm the diagnosis but the condition can be so painful that they are not often used.

Numbing the sacroiliac joint with local anesthesia usually confirms the diagnosis if the pain disappears while the medication is active. Adding steroids (cortisone derivatives) will decrease the inflammation and help treatment. However, if the joint remains in an abnormal position, the pain usually comes back.

Conservative treatment consists in realigning the joint with appropriate manipulations, then strengthening the tendons and surrounding muscles with exercises to keep it in position. Sometimes, a sacroiliac belt that tightens around the hips might be of use.

Some clinicians use sclerotherapy (prolotherapy). This is a technique where irritant substances are injected in the ligaments and tendons that surround the joint to produce inflammation and scarring. This thickens the ligaments and may stabilize the joint. However, this technique is not presently accepted by the medical community at large and most of the insurance companies.



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