Sacroiliac Joint Syllabus

PACIFIC UNIVERSITY

School of Physical Therapy

DPT 631 Musculoskeletal Examination and Intervention for the Neck and Trunk SIJ EXAMINATION & INTERVENTION Peter Huijbregts, PT, OCS, FAAOMPT ANATOMY

A. Osteology • • • •

Frontal plane wedge shape tapering from superior to inferior. Lateral part of S1 is oriented 20 to 25 degrees laterally to the para-sagittal plane in an A/P direction; lateral part of S2 oriented 10 to 15 degrees laterally; lateral part S3 oriented 0 to 5 degrees medially to para-sagittal plane (Dijkstra, 1997). Lateral aspect sacrum resembles the undulated shape of a propeller (Snijders et al, 1997) Ridges and depressions: complementary irregularities of cartilage and underlying bone (Vleeming et al, 1990).

B. Arthrology • • • • • • •

L-shaped auricular surfaces with a shorter superior, vertical portion on the lateral surface of S1 and a longer inferior, more horizontal part extending across S2 (S3). Inter- and intra-individual (left-right) differences (Bernard and Cassidy, 1991). Sacral cartilage typical hyaline cartilage. Iliac cartilage may resemble fibro-cartilage; histologically it is also hyaline cartilage (Bernard and Cassidy, 1991). Joint surface texture: non-complimentary cartilaginous irregularities increase friction coefficient (Vleeming et al, 1990). Confuting reports in literature re: reciprocal ridges and gutters on joint surfaces. Possible accessory (supernumerary) sacroiliac joints in 8 to 36% of the population (Bernard and Cassidy, 1991). They may be syndesmoses or synovial joints. They can occur single, double, or triple (Schunke, 1938). Their joint plane orientation may vary up to 60% with auricular joint plane (Walker, 1992).

C. Ligamentous structures (Alderink, 1991; Gray and Clemente, 1984; Willard, 1997) •

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Interosseus sacroiliac ligament: located between the sacral and iliac tuberosities, dorsocranial to SIJ; may blend with posterior SIJ capsule. Ventral sacroiliac ligament: thickening anterior SIJ capsule. Short posterior sacroiliac ligament: runs nearly horizontal from first and second transverse tubercle on dorsal surface sacrum to iliac tuberosity. Long posterior sacroiliac ligament: covers short posterior sacroiliac ligament; runs from second to fourth transverse tubercle to PSIS. Sacrotuberous ligament: 1. Lateral band connects PIIS to ischial tuberosity. 2. Medial band runs from lateral coccyx to ischial tuberosity. 3. Superior band runs from PSIS to lateral coccyx. 4. Central bands run between lateral band and the fourth and fifth transverse tubercles of the sacrum. Sacrospinous ligament: lower lateral sacrum and coccyx to ischial spine.

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All ligaments resist nutation; only the long posterior sacroiliac ligament resists counternutation.

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D. Myology • • • • • •

Role and anatomical connections of the thoracolumbar fascia (TLF) as described earlier. Dorsal sacroiliac ligaments connect medially to the TLF (Alderink, 1991). Tendons of the deepest lamina of the multifidus muscle extend into sacrotuberous ligament (Willard, 1997). Piriformis and gluteus maximus muscles are continous with sacrotuberous ligament (Vleeming et al, 1989). Biceps femoris tendon is continous with sacrotuberous ligament (Vleeming et al, 1989; Van Wingerden et, 1997). Sacrospinous ligament is attachment site for pubococcygeus muscle (Gray and Clemente, 1984).

DPT 631 SPINE

SIJ Examination & Intervention - 1

PACIFIC UNIVERSITY

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School of Physical Therapy

Extensions of the aponeuroses of the transverse abdominis, rectus abdominis, pyramidalis, internal oblique, adductor longus, and graciis muscles reinforce the anterior pubic ligament (Kapandji, 1986); due to distance to SIJ these muscle can exert strong stabilizing compressive moments on SIJs

BIOMECHANICS

A. Osteopathic concepts (Alderink, 1991; Greenman, 1990) • • • • • • • • • • • •

Osteopathic theory distinguishes between iliosacral and sacroiliac motions. Iliosacral motion: forces originate in the lower extremity. Sacroiliac motion: forces originate in the spine. Three types of iliosacral motion: anterior/ posterior rotation innominate; inferior/superior innominate translation; inflare/ outflare. Downslip/ upslip: inferior and superior translation in the frontal plane along a vertical axis occurs in subjects with flattened, parallel joint surfaces (15% population). Inflare/ outflare: rotation of the innominate around a vertical axis in a transverse (horizontal) plane; only in joints with reversed concave-convex relationship. Sacroiliac motion: nutation/ counternutation; motion about an oblique axis. Nutation and counternutation are not osteokinematic movements or simply movements of the sacrum in space. They are arthrokinematic movements: movement of the sacrum is described in relation to a presumed stationary innominate bone. Nutation: motion in which the sacral promontory moves antero-inferiorly and the coccyx and apex of the sacrum move postero-superiorly. Counternutation: motion in which the sacral promontory moves postero-superiorly and the coccyx and the apex of the sacrum move antero-inferiorly. Multiple frontal plane axes for sacral (counter) nutation. Motion around an oblique axis occurs with gait. There are two oblique axes: the left oblique axis runs between the left upper and right lower pole of the SIJ, the right oblique axis runs from the right upper pole to the left lower pole. Motion around an oblique axis is defined as rotation of the anterior sacral surface to one side with contralateral sidebending of the superior surface.

B. Research summary • • • • • •

Joint surface orientation, joint surface irregularities, and ligamentous laxity determine type and extent of movement available in SIJ (Weisl, 1954; Wilder et al,1980) Pure translation or rotation can only occur in SIJ if sufficient ligamentous laxity allows for unlocking joint surfaces; distraction of 7.25 mm needed for pure translation to occur (Wilder et al, 1980). Research shows main motion occurring in SIJ is (counter)nutation; these movements take place mainly in the sagittal plane. The three-dimensional orientation of the joint surfaces may explain apparent minimal rotation/translation observed around other two orthogonal axes/planes, i.e. movements in the transverse plane (inflare and outflare) or motions in the frontal plane (upslip and downslip) (Huijbregts, 2001a). Osteopathic concepts may have a role in explaining mobility in SIJ allowing excessive mobility (Huijbregts, 2001a). “A unifying model of sacroiliac function has not been presented, supported, or verified…” (Alderink, 1991).

C. Form and force closure • • •

Musculoskeletal Research Group, Erasmus University, Rotterdam, The Netherlands. Form closure: stable situation with closely fitting joint surfaces: no extra forces are needed to maintain the state of the system given the current load situation (Vleeming et al, 1997). Aspects of form closure in the SIJ are: 1. Increased friction coefficient due to rough joint surface texture. 2. Complimentary osseocartilaginous ridges and depressions on the auricular surfaces. 3. Undulated shape of the joint surfaces (resembling a propeller). 4. Frontal plane wedge shape of the sacrum.

DPT 631 SPINE

SIJ Examination & Intervention - 2

PACIFIC UNIVERSITY

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School of Physical Therapy

However, perfect form closure does not allow for SIJ movement; it would not allow the SIJ to dissipate forces converging in the pelvic region; a combination of force and form closure does allow for movement. Force closure: lateromedially directed forces are needed to increase intra-articular friction and thus resist the shear forces resulting from vertical lumbosacral loading (Snijders et al, 1997). Because of the existence of force closure the body needs a system to control SIJ mobility: this system has ligamentous, muscular, and of course neural components.

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Self-locking or self-bracing is fundamental to force closure. Sacral nutation is essential for this self-locking mechanism: it increases the tension in the interosseus, short posterior sacroiliac, sacrotuberous, and sacrospinous ligaments; these ligaments pull the innominates closer together, thereby increasing compression in the SIJ (Vleeming et al, 1997).

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Muscles can contribute in multiple ways to force closure: 1. Piriformis, gluteus maximus, iliococcygeus, and ischiococcygeus muscles can approximate the sacrum and innominate by their insertion on both bones (Lee, 1999). 2. The lumbar multifidus and erector spinae muscles can approximate the innominates posteriorly by their insertion into the iliac bones (Vleeming et al, 1997). 3. Sacral attachments of the multifidus muscle contribute to self-locking by their nutation action on the sacrum (Vleeming et al, 1997). 4. The anterior (abdominal) muscles have a “nut-cracker” effect through their insertion ventral to the SIJs in the prepubic aponeurosis (Snijders et al, 1997). 5. The gluteus maximus, the long head of the biceps femoris, the piriformis and the deep lamina of the multifidus can increase tension in the sacrotuberous ligaments (Van Wingerden et al, 1997; Vleeming et al, 1989). 6. The pelvic floor muscles can increase sacrospinous ligament tension (Lee, 1999). 7. The quadratus lumborum may affect the ventral sacroiliac ligament tension through their mutual connection to the iliolumbar ligament (Lee, 1999). 8. The L5 longissimus fascicle inserts into the ventral sacroiliac ligaments. 9. The muscles inserting into the TLF may increase compressive forces over the SIJ (Vleeming et al, 1997). 10. Hydraulic amplifier mechanism: swelling of the erector spinae group with contraction increases tension in TLF enclosing it (Vleeming et al, 1997).

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Failed self-locking may occur due to (Vleeming et al, 1992, 1997): 1. Ligamentous laxity resulting from repetitive microtrauma (high-level athletics, gymnastics, occupational stresses). 2. Ligamentous laxity from relaxin-induced decrease mechanical properties ligaments (peri-menstrual, during and after pregnancy). 3. Decreased muscle performance (deconditioning, detraining, overtraining, excessive occupational stresses). 4. A flat back posture in an attempt to compensate for a painful condition elsewhere (painful post-partum symphysis pubis, facet joint pain, posterior disk irritation, etc) causes sacroiliac counternutation and thus loss of self-bracing. 5. Degenerative osseochondral or chondral lesions affecting reciprocal rides and depressions or surface texture. 6. Sacral and pelvic fractures. Accepting the form and force closure model implies accepting that all SIJ dysfunctions are caused by a failure of form and force closure. Loss of stability has to precede a possible loss of mobility. This explains why treatments may include pain modulation and joint mobilization, but will always include attempts at restoring the self-locking mechanism.

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D. Cardinal plane biomechanics • • • •

Trunk flexion results in sacral nutation. This nutation provides for stability due to the self-locking mechanism (Colachis et al, 1963; Stureson et al, 1989; Stureson, 1997). Trunk flexion in standing increases hamstrings muscle tension. This adds to SIJ stability by increasing sacrotuberous ligament tension and force closure (Vleeming et al, 1997). Counternutation sometimes hypothesized to occur near the end of flexion (Lee, 1999) unlikely. Delordozation or adopting a flat back posture in standing may cause sacral counternutation (Vleeming et al, 1997).

DPT 631 SPINE

SIJ Examination & Intervention - 3

PACIFIC UNIVERSITY

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School of Physical Therapy

Trunk extension in standing also results in sacral nutation. Trunk extension in prone may cause sacral counternutation (Meadows, 1999; Stureson et al, 1989; Stureson, 1997). Trunk sidebending and rotation are unlikely to cause SIJ sidebending or rotation. Trunk sidebending causes ipsilateral anterior rotation and contralateral posterior innominate rotation (Meadows, 1999). Trunk rotation may also induce innominate rotation motions due to its associated coupled motion of sidebending. The pattern or direction of these innominate rotations as a result of trunk rotation is unknown and likely variable between persons and situations. The direction of coupled sidebending and the amount of trunk weight lateral to the midsagittal plane may determine which innominate motion takes place (Huijbregts, 2001a)

EXAMINATION • • •

The biomechanical classification system uses the extrapolation of (patho)anatomical and (patho)biomechanical knowledge to guide examination, diagnosis, and treatment. Face validity and construct validity may seem high. However, reliability and validity (sensitivity and specificity) of physical tests often unproven or questionable.

A. Provocation tests • • • •

In the biomechanical system negative provocation tests are used to rule out SIJ dysfunction. Positive tests do not necessarily implicate SIJ as source of symptoms: as discussed in the examination of the lumbar spine, we need to clear the lumbar spine and hip before we can assume with more certainty that positive SIJ provocation tests implicate the SIJ as the source of symptoms. Discussed previously: distraction test, compression test, thigh thrust test, pelvic torsion (Gaenslen) test, sacral thrust test. Meadows (1999) classified the distraction and compression tests as primary provocation tests: positive tests indicate a more irritable SIJ. Intervention consists mainly of anti-inflammatory modalities and (relative) rest.

B. Positional palpation tests •

Palpation of bony landmarks: ASIS, PSIS, iliac crests, and greater trochanters. Patient is standing, therapist sits on stool behind (and in front) of the patient. These tests give information on functional leg length differences (greater trochanters) and innominate position. Innominate positional faults are posterior and anterior innominate rotation and inferior or superior translation. They do not provide information as to the presence of dysfunction or the side of dysfunction.

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Question: A patient presents with equal greater trochanter and iliac crest levels, lower right PSIS, and lower left ASIS. What is the dysfunction present? 1. Posterior right innominate rotation. 2. Anterior left innominate rotation. 3. A combination of the previous two dysfunctions. 4. No dysfunction.

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Write up positional palpation findings for: 1. Posterior right innominate rotation with right shorter leg. 2. Posterior right innominate rotation with right superior innominate translation.

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Osteopathic concepts include positional palpation of the sacral sulcus (the area just medial to the PSIS) and the inferior lateral angle (the lateral inferior pole of the sacrum) to determine sacral rotation and sidebending positional faults. These tests are usually done with the patient prone. Remember the poor intra- and interrater reliability of positional tests (O’Haire and Gibbons, 2000)

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C. Active motion palpation tests • •

Used by physical therapists, chiropractors, osteopaths, and medical doctors. Palpation of bony landmarks during active movements may give information on relative mobility. Active motion palpation tests do not indicate whether the relatively hypomobile side is indeed hypomobile, or whether this side is normal with a contralateral hypermobility.

DPT 631 SPINE

SIJ Examination & Intervention - 4

PACIFIC UNIVERSITY

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School of Physical Therapy

Combining active motion palpation tests with provocation tests may give a better indication of the symptomatic side. Decreased mobility in the left SIJ with a positive provocation test for the left SIJ implicates left SIJ hypomobility. Decreased left mobility with a right positive provocation test may implicate a symptomatic right hypermobility and normal mobility left. Poor reliability.

Standing flexion test (Meadows, 1999; Van der El, 1992; Winkel, 1991)

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Patient position: standing with back towards therapist. Therapist position: sitting on a stool behind the patient. Hand placement: the therapist palpates PSIS with thumb of the ipsilateral hand and the S2 spinous process with the thumb of the contralateral hand.

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Test: palpation of relative movement of both bony landmarks during trunk flexion. Normal response: the S2 spinous process initially moves upward and forward relative to PSIS (sacral nutation), then relative movement stops and PSIS moves upward and forward (hip flexion). Positive test: asymmetry in relative motion S2-PSIS when comparing sides. False positive tests: may result from SIJ asymmetry, bony pelvic asymmetry, rotation position lumbar vertebrae, differences in hamstrings muscle length, or leg length discrepancies. (Alternative test #1: seated flexion test eliminates leg length discrepancies and effect of hamstrings muscle length.) (Alternative test #2: palpation of both PSIS allows for direct comparison between SIJs.)

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SIJ Examination & Intervention - 5

PACIFIC UNIVERSITY

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Gillet test (Magee, 1997; Meadows, 1999; Van der El, 1992) • • •

Patient position: standing with back towards the therapist. Therapist position: sitting on stool behind the therapist. Hand placement: the therapist palpates the PSIS with the ipsilateral thumb and the S2 spinous process with the contralateral thumb.

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Test: palpation of relative motion between landmarks during ipsilateral hip (and knee) flexion; patient is allowed to hold on to support to help with balance. Normal response: PSIS initially moves downward and backward relative to S2 (posterior innominate rotation), then relative movement stops and both landmarks move together. Positive test: asymmetry in relative motion S2-PSIS when comparing sides. (Alternative test: palpation of both PSIS during hip flexion; due to body weight causing self-locking on side of the stance leg no motion should be available there.)

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Supine-to-long sitting test (Magee, 1997) • Patient position: supine, feet over the edge of the bed, medial malleoli leveled by bridging motion. • Therapist position: standing at the foot end of the bed. • Hand placement: holding the patient’s medial malleoli with thumbs of therapist touching each other. • Test: patient is asked to sit up while therapist observes for one malleolus moving up further towards the therapist than the other malleolus. • Positive test: apparent lengthening of the leg from supine to long sitting may indicate posteriorly rotated innominate on the ipsilateral side and/or an anteriorly rotated innominate on the contralateral side.

Ipsilateral sidebending test (Meadows, 1999)

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DPT 631 SPINE

Patient position: standing with back towards therapist. Therapist position: sitting on a stool behind the patient. Hand placement: one hand palpates S2 spinous process, other hand palpates PSIS on the side to which the patient is going to sidebend. Test: palpation of relative motion during ipsilateral trunk sidebending. Normal response: during sidebending the ipsilateral innominate rotates anteriorly. Positive test: asymmetry in relative motion S2-PSIS when comparing sides.

SIJ Examination & Intervention - 6

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Contralateral sidebending test (Meadows, 1999)

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Patient position: standing with back towards therapist. Therapist position: sitting on a stool behind the patient. Hand placement: one hand palpates S2 spinous process, other hand palpates PSIS on the side from which the patient is going to bend away. Test: palpation of relative motion during contralateral trunk sidebending. Normal response: during sidebending left the contralateral innominate rotates posteriorly. Positive test: asymmetry in relative motion S2-PSIS when comparing sides.

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Question: during the standing flexion test with palpation on both PSIS, the right PSIS moves upward and forward sooner than the left PSIS. What is the dysfunction present? 1. Right SIJ hypomobility. 2. Left SIJ hypermobility. 3. A combination of both dysfunctions above. 4. A shorter left hamstrings muscle.

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Question: What is the most appropriate test to determine the side of a possible SIJ dysfunction in the case of positive findings on the active motion palpation tests? 1. Positional palpation tests. 2. Provocation tests. 3. Passive physiological motion tests.

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Describe the findings on all active motion palpation tests in case of: 1. A left SIJ hypomobility without positional fault. 2. A left SIJ hypomobility with a posterior innominate rotation positional fault. 3. A right SIJ hypermobility.

D. Passive physiological motion tests (Van der El, 1992) • • •

Aka. passive motion palpation tests. Poor reliability. Considering the combination of patient report of pain and restriction of motion as a positive may improve reliability and validity.

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The endfeel on PPM tests may give indication of type of restriction: 1. Muscular endfeel (increasing stiffness coefficient) may implicate hypertonicity or adaptive shortening. 2. Hard capsular endfeel (high stiffness coefficient) may implicate capsuloligamentous shortening. 3. Pathomechanical endfeel (springy endfeel) may implicate subluxation (dissociation of complementary osseochondrous ridges and depressions with locking a couple of joint surface irregularities over). 4. Empty endfeel (limited by pain) may implicate irritable SIJ dysfunction, e.g. due to an inflammatory process.

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Together with provocation and positional palpation tests (and active motion palpation tests) can indicate location (side) and direction of hypomobility.

DPT 631 SPINE

SIJ Examination & Intervention - 7

PACIFIC UNIVERSITY

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Anterior innominate rotation test

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Patient position: prone. Therapist position: standing on opposite side. Hand placement: heel of proximal hand placed on apex of sacrum, index finger distal hand palpates SIJ joint line at level of PSIS. Test: proximal hand applies ventromedial pressure on apex of the sacrum. Results: range of motion, endfeel, quality of motion, reproduction of symptoms. Remarks: passive test for sacral counternutation.

Posterior innominate rotation test

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Patient position: prone. Therapist position: standing on opposite side. Hand placement: distal hand cups the ventral iliac crest at the ASIS, proximal hand palpates at the SIJ joint line at the level of the PSIS. Test: by way of lumbrical action the distal hand moves the innominate into posterior rotation. Results: range of motion, endfeel, quality of motion, reproduction of symptoms. Remarks: passive test for sacral nutation.

DPT 631 SPINE

SIJ Examination & Intervention - 8

PACIFIC UNIVERSITY

School of Physical Therapy

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Question: provocation tests cause pain in the left SIJ region. Positional palpation reveals a higher left ASIS and a higher right PSIS; iliac crests and trochanters are equal. The standing flexion test revealed a relative hypomobility of the left SIJ. The left anterior innominate rotation test is restricted with a hard capsular endfeel. The left posterior innominate rotation test is normal. What is the most likely dysfunction present? 1. Right sacroiliac hypermobility. 2. Left anterior innominate rotation restriction due to capsuloligamentous shortening. 3. Left posterior innominate rotation restriction due to capsuloligamentous shortening.

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Question: are the positional palpation results necessary to make your diagnosis?

Functional stability tests • •

These tests may indicate the presence of instability. Instability can result from: 1. Active subsystem deficiency. 2. Neural control subsystem deficiency. 3. Passive subsystem deficiency. 4. Any combination of subsystem deficiencies.

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These tests do not allow us to make a decision as to which subsystem is deficient. Remember that active and neural control subsystem deficiency may affect force closure and therefore stability without passive subsystem deficiency. Further tests are needed to determine (type of) contribution of the different subsystems, e.g. structural stability and muscle function tests (discussed later).

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Supine active straight leg raise test (Lee, 1999) • Patient position: supine. • Therapist position: standing on ipsilateral side (side of SLR). • Test #1: the patient actively raises straight leg by flexing the hip. • Positive test: production of pain, rotation of the pelvis towards the leg being raised, crepitus, decreased ease of active SLR all indicate SIJ instability. • Test #2: the therapist places both hands on lateral aspects of the patient’s iliac crests (at the level of the PSIS) and approximates crests increasing compressive forces over SIJs. • Test #3:the therapist places the proximal hand on the opposite shoulder of the patient; patient performs static trunk flexion and rotation towards the therapist. • Positive test: decrease in symptoms and/or increased ease of active SLR with either test #2 or test #3 indicates SIJ dysfunction which is positively affected by increased force closure.

Prone active straight leg raise test (Lee, 1999) • Patient position: prone. • Therapist position: stand on ipsilateral side (side of SLR). • Test #1: the patient actively raises the leg by extending the hip. • Positive test: production of pain, crepitus, decreased ease of active SLR, alteration muscular recruitment (normally first ipsilateral hamstrings, then ipsilateral gluteus maximus, and then contralateral erector spinae group), excessive rotation pelvis in transverse plane. • Test #2: the therapist places both hands on the lateral aspects of the patient’s iliac crests and manually compresses the SIJs. • Test #3: the therapist resists extension at the shoulder of the contralateral arm (isometric contraction latissimus dorsi muscle). • Positive test: decrease in symptoms and/or increased ease of active SLR with either test #2 or test #3 indicates SIJ dysfunction positively affected by increased force closure.

DPT 631 SPINE

SIJ Examination & Intervention - 9

PACIFIC UNIVERSITY

School of Physical Therapy

SIJ-belt test (Vleeming et al, 1992) • Test: patient repeats movements reported and demonstrated as painful after application of a sacroiliac belt. • Positive test: decrease in symptoms when using a belt indicates SIJ instability affected by force closure. •

Question: the patient complains of sacroiliac region pain with ADL. The therapist has the patient perform the supine straight leg raise left. It is painful and the patient appears to have problems lifting the leg. Increasing force closure decreases pain and increases the ease of motion. What dysfunction is likely at this point in the examination? 1. A right sacroiliac instability. 2. A left sacroiliac passive subsystem deficiency. 3. A left sacroiliac active subsystem deficiency. 4. A left sacroiliac neural control subsystem deficiency.

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Question: the patient reports pain in the SIJ region. Provocation tests were all positive. Active and passive motion palpation tests reveal no hypomobility. Positional palpation is normal. Stability screening tests are painful, yet increasing force closure does not affect or even increases the complaints. What is the most likely explanation? 1. Insufficient force used for force closure. 2. Inflammatory lesion SIJ causes pain with compressive force applied. 3. Complaints are not related to SIJ.

E.

Passive accessory motion/ structural stability tests (Meadows, 1999)

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In the biomechanical system, accessory motion tests are used to assess the motion behavior of a joint by way of attention to the glides associated with its (angular) physiological motions. E.g. decreased glenohumeral abduction with normal caudal glide of the humerus in the restricted position excludes capsuloligamentous restrictions as the cause of the restriction in physiological motion. E.g. decreased trunk flexion with a hard endfeel and decreased motion on low lumbar P/A implicates the capsuloligamentous structures of the lumbar spine.

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Stability tests can implicate joint instability. This instability is generally the result of traumatic or degenerative changes. Instability tests attempt to assess motions that should not be possible in a normal joint. Testing the accessory motions of the SIJ is impossible: research shows that translatory motion only occurs in the case of capsuloligamentous laxity. Therefore, tests of the accessory motion theoretically available in the SIJ double in this case as our stability tests. PAM tests will normally show very minimal motion: the biomechanical system uses the endfeel on this very minimal motion to diagnose the type of hypomobility possibly present (Meadows, 1999).

Dorsal innominate shear test (same as posterior shear/thigh thrust practiced with SIJ scanning) • Patient position: supine, ipsilateral hip flexed to approximately 90 degrees and slightly adducted. • Therapist position: standing contralateral of the side to be tested. • Hand placement: distal hand palpates both PSIS and sacral surface, proximal hand placed on the ipsilateral knee of the patient. • Test: take up slack SIJ by sustained axial compression through femur attempting to shear innominate dorsally on sacrum. • Positive test: motion between sacrum and innominate indicates passive subsystem deficiency. • Remark: similar to the thigh thrust test described as a provocation test with the exception of sustained pressure and palpation at the SIJ joint line.

DPT 631 SPINE

SIJ Examination & Intervention - 10

PACIFIC UNIVERSITY

School of Physical Therapy

Caudal shear test

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Patient position: prone. Therapist position: standing on side to be tested. Hand placement: distal hand stabilizes sacrum by cranial pressure on the apex of the sacrum, fingers point cranially; proximal hand placed on PSIS or iliac crest, fingers point in a caudal direction. Test: proximal hand applies sustained caudal-proximal pressure along the SIJ joint line. Positive test: motion between sacrum and innominate indicates passive subsystem deficiency.

Cranial shear test

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Patient position: prone. Therapist position: standing on side to be tested. Hand placement: proximal hand stabilizes sacrum by caudal pressure at the base, fingers point towards the feet; distal hand placed on ischial tuberosity or PSIS, fingers point towards the patient’s head. Test: distal hand applies cranial-lateral force along SIJ joint line. Positive test: motion between sacrum and ilium indicates passive subsystem deficiency.

F.

Muscle function tests

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May involve length, strength, endurance, and coordination tests of all muscles contributing to force closure. May include multifidus and transverse abdominis muscle tests described by Richardson et al (1999). Do not forget the effects of lower extremity muscle imbalance on load transfer through SIJ. E.g. left gluteus medius weakness may result in a left Trendelenburg gait with increased vertical shear forces applied to the left SIJ.

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DIAGNOSIS • • • • • • •

The only tests seemingly reliable and valid for SIJ dysfunction are some of the provocation tests. Positive provocation tests may implicate or exclude the SIJ as a source of complaints, but provide no further information on appropriate interventions. Diagnosis and treatment are based solely on extrapolation of (patho) anatomical and (patho)biomechanical knowledge. The assumption that hypomobility can only occur as a result of an underlying instability, means that we always need to diagnose and treat instability in all SIJ-dysfunctions. SIJ dysfunction classification is theoretical and not standardized across all therapists (Huijbregts, 2001b). The dysfunction presented is also based on the assumption that only innominate rotation and translation dysfunctions are relevant. An SIJ biomechanical diagnosis includes: 1. Location: left, right, or bilateral. 2. Type of hypomobility: extra-articular, capsuloligamentous, or pathomechanical. 3. Direction of hypomobility: anterior innominate rotation, posterior innominate rotation, inferior innominate translation, superior innominate translation, or combinations. 4. Underlying type of instability: combined subsystem or active/neural control subsystem deficiency.

A. Combined subsystem deficiency • • • • • • • • •

PRIMARY FOCUS OF TREATMENT: stabilization. Deficiency of form closure, e.g. due to degenerative loosening osseochondral ridges and depressions, changes in joint surface texture and compressibility, fractures (Vleeming et al, 1992) Deficiency of force closure: capsuloligamentous laxity and/or neuromuscular dysfunction. Probably positive provocation tests. Possibly abnormal positional palpation findings, especially in asymmetric weight bearing positions. Assymetry of motion on active motion palpation tests. Hypermobility on PPM and PAM tests. Positive functional stability tests. Positive muscle function tests.

B. Active and neural control subsystem deficiency • • • • • • • •

PRIMARY FOCUS OF TREATMENT: stabilization, addressing causal dysfunctions. No deficiency of form closure. Deficiency in self-locking. Probably positive provocation tests. Negative positional palpation tests, except in case of antalgic flat back posture. Symmetrical mobility on active motion palpation, PPM, and PAM tests. Possitive functional stability and muscle function tests. Look for causal dysfunction in antalgic flat back posture.

C. Pathomechanical hypomobility • • • • • • • •

PRIMARY FOCUS OF TREATMENT: manual mobilization, muscle energy techniques. Hypothesis: capsuloligamentous laxity allows for unlocking joint surfaces and again locking on a different set of osseochondral ridges and depressions. Provocation tests probably positive. Positive positional palpation findings. Anterior innominate rotation due to loss of self-bracing. Posterior innominate rotation due to axial forces along the femur with acetabulum ventral to SIJ. Superior innominate translation caused by sudden ground reaction forces. Inferior innominate translation caused by traction force on leg, e.g. falling forwards with foot caught in stirrups or ladder (Lee, 1999).

DPT 631 SPINE

SIJ Examination & Intervention - 12

PACIFIC UNIVERSITY

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School of Physical Therapy

Inferior and superior translation make it very hard for the patient to bear weight on the affected leg (Meadows, 1999). Inferior and superior translation may indicate greater instability (Lee, 1999). Assymetry of motion on active motion palpation tests. Hypomobility on PPM tests. Pathomechanical endfeel with even more restricted ROM on PAM tests. Positive functional stability and muscle function tests.

D. Capsuloligamentous hypomobility • • • • • • • • •

PRIMARY FOCUS OF TREATMENT: manual mobilization, muscle energy techniques. Hypothesis #1: capsuloligamentous shortening results from long-standing pathomechanical hypomobility. Hypothesis #2: resulting from excessive tension due to subluxation which thereafter simultaneously reduces. Positive provocation tests. Positional palpation tests positive (hypothesis #1) or negative (hypothesis #2). Assymatry in motion on active motion palpation tests. Hypomobility on PPM tests. Hypomobility on PAM tests with hard capsular endfeel. Positive functional stability and muscle function tests.

E. Extra-articular hypomobility • • • • • • • • • •

PRIMARY FOCUS OF TREATMENT: stretching, inhibition. Apparent joint-related hypomobility, but with an extra-articular cause. Nociception in SIJ may increase local muscle tone by somatosomatic and somatosympathetic reflex circuits (Van der El, 1992). Attempts at joint stabilization may also result in excessive tone. Possibly positive provocation tests (if nociception caused hypertonicity). Possibly positive positional palpation tests. Assymetry of motion on active motion palpation. Hypomobility on PPM tests. Normal findings on PAM tests. Positive functional stability and muscle function tests.

TREATMENT

A. Pain modulation • • •

Can include physical modalities (e.g. thermotherapy, diathermia, cryotherapy, ultrasound therapy) or grade I and II oscillatory techniques. Sacroiliac belt may minimize strain SIJ tissues (Vleeming et al, 1992). ADL advice to decrease torsional strain on SIJs: careful with reciprocal movement pelvic region (walking, running, stairs), excessive hip abduction during intercourse, unilateral loads (lifting in sidebent or rotated position, standing on one leg).

B. Manual mobilization • • • •

Can include mobilization, manipulation, and muscle energy techniques. Contract-relax, sustained stretching, and inhibitory techniques are indicated in extra-articular hypomobility (Meadows, 1999). Muscle energy techniques and grade IV or sustained endrange mobilization are indicated in capsuloligamentous hypomobility (Meadows, 1999). Grade III+ mobilization or manipulation is indicated in pathomechanical hypomobility (Meadows, 1999).

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For the entry-level clinician, both pathomechanical and capsuloligamentous hypomobilities can effectively be treated with manual mobilization (grade III, IV, and sustained endrange) and/or muscle energy techniques. Described are techniques to affect innominate rotation and/or superior or inferior translation.

Posterior innominate rotation mobilization (Meadows, 1999; Winkel, 1991) • Patient position: sidelying on unaffected side, trunk rotated maximally to the affected side to lock lumbar spine. The hip on the unaffected side is extended until the PSIS on that side starts to move; the hip on the affected side is flexed until the PSIS on the affected side starts to move. • Therapist position: standing ventral to the patient, the patient’s affected side lower leg is either resting on the therapist’s stomach or is wrapped around the therapist’s back. • Hand placement: the therapist places the proximal hand on the ASIS, the distal hand over the ischium. • Mobilization: posterior innominate rotation through dorsal-distal-medial force at the ASIS and ventral-proximal-lateral force at the ischium.

Posterior innominate rotation muscle energy technique • Similar patient and therapist position and technique set-up. • Isometric contraction into hip extension uses hamstrings and gluteus maximus muscles to produce posterior innominate rotation.

Anterior innominate rotation mobilization #1 (Van der El et al, 1993) • Patient position: prone. • Therapist position: standing on the contralateral side. • Hand placement: heel of cranial hand stabilizes on contralateral apex of the sacrum, the caudal hand is placed on the iliac crest at the level of the PSIS. • Mobilization: the hand on the PSIS exrts a force in a ventral-cranial-lateral direction. Anterior innominate rotation mobilization #2 (Van der El et al, 1993; Winkel, 1991) • Patient position: prone with the trunk extended, sidebend and rotated towards affected SIJ, as close as possible to the contralateral side of the bed. • Therapist position: standing on the contralateral side. • Hand placement: cranial hand is placed on the iliac crest at the PSIS, the caudal hand is placed on the ventral-distal thigh and lifts the leg, close packing the hip into extension. • Mobilization: the cranial hand pushes in a ventral-proximal-lateral direction. • Variation: by placing the foot of the non-affected side on the ground on the foot of the therapist the unaffected SIJ is also locked.

Anterior innominate rotation muscle energy technique • Patient position: supine, hip unaffected side maximally flexed, hip affected side extended (Thomas test position off the end of the bed). • Therapist position: standing at the foot end of the bed, foot of the patient’s flexed hip in the therapist’s flank. • Hand placement: one or two hands on ventral dis tal thigh extended leg. • Mucle energy technique: isometric hip flexion, or alternatively knee extension, uses iliacus or rectus femoris muscles to anteriorly rotate innominate.

Caudal innominate translation mobilization (Meadows, 1999) • Patient position: prone, legs slightly over end of the bed. • Therapist position: standing at the foot end of the bed, straddling the leg of the patient’s affected side and holding the malleolar area between the legs. • Hand placement: leaning forward the therapist stabilizes the sacral apex and the dorsal aspect of the sacrum with both hands. • Mobilization: therapist produces caudal force by moving buttocks backwards. DPT 631 SPINE

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Cranial innominate translation mobilization (Meadows, 1999) • Patient position: prone. • Therapist position: on foot end of the bed at the contralateral side. • Hand placement: assistant stabilizes by pushing cranially on the ipsilateral ischial tuberosity. The therapist lifts the contralateral leg into extension-abduction-internal rotation (close packed position) at the ankle. • Mobilization: the therapist pulls along the long axis of the contralateral leg. C. Stabilization • • •

May include strength, endurance, and coordination training of all muscles capable of increasing force closure. May also include coordination training of local muscle system of the lumbar spine (multifidus and transverse abdominis muscles). Sacroiliac belt or tight fitting spandex pants may increase force closure SIJ.

D. Treatment other regions/ contributing factors • • • • • • • •

A flat back posture may cause sacral counternutation with resultant failure of self-locking (Vleeming et al, 1997). Addressing the causal dysfunction responsible for the flat back posture is necessary to affect SIJ dysfunction, e.g. a postpartum painful symphysis pubis, a painful zygapophysial joint dysfunction, a posterior disk lesion, stenotic syndromes, muscular dysbalances, etc. Restrictions in the lower extremity may increase the load on the SIJ. E.g. decreased hip extension (whether capsular or muscular) will decrease contribution hip during late stance phase possibly increasing anterior innominate rotation with decreased self-locking. Weakness and dyscoordination in the lower extremity may affect SIJ function. E.g. excessive pronation may cause internal rotation of the tibia leading to internal rotation of the femur. This will decrease hip contribution in late stance, but also affect piriformis length and hip abductor efficiency. Neurologic deficits due to lower lumbar radiculopathy may affect the SIJ mechanics. E.g. L5 weakness may affect gluteus medius, S1 weakness may decrease gluteus maximus strength.

REFERENCES • • • • • • • • • • • • •

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