Sij Presentation Slides.pdf

Sacro-iliac Joint Pain 1st September 2018

Presenters: Michael Dermansky – Senior Physiotherapist and Managing Director Nicole Davies – Accredited Exercise Physiologist Stephen Panagos – Physiotherapist A: 737 High Street, Kew East, VIC, 3102 T: 03 9857 0644 F: 03 9819 7233 W: mdhealth.com.au E: [email protected]

The Sacro-iliac Joint (SIJ) • Introduction • SIJ Theory – • Anatomy & Pathologies • SIJ Assessment • Function & Stability testing • Strength testings • Other tests to help diagnosis • Significant Findings & Treatments • Case Studies

About MD Health: • Comprise of Physiotherapists and Exercise Physiologists • Work with variety of people • Apparently healthy • Musculoskeletal pathologies/injuries • Neurological and Cardiovascular Diseases • Full Body Assessments > Reassessments • Individualised treatment plans • Injury Rehabilitation • Injury • Surgery – Pre and Post • General aches & pains • Pilates and Strength & Conditioning Training • Core stability • Strengthening • Cardiovascular Assessment/Rehab & High Intensity Interval Training

SIJ - Theory • Anatomy and Kinematics • Pathophysiology

The Pelvic Girdle A region that supports the abdomen and the organs of the lower pelvis and also provides a dynamic link between the vertebral column and the lower limbs. Diane Lee, The Pelvic Girdle – an approach to the examination and treatment of the lumbopelvic-hip region

SIJ Anatomy Overview • The SIJ is diathrodial (synovial anterior and fibrous posterior) • The articulating surfaces of the sacrum are C-shaped and become grooved in adulthood • SIJ movements are nutation (superior sacrum tips anteriorly) and counter-nutation (superior sacrum tips posteriorly), and lesser amounts of torsion and translation • Supported by active and passive systems and structures

http://en.wikipedia.org/wiki/Sacroiliac_joint

SIJ Anatomy Overview Passive system The pelvis and Sacro-Iliac Joint (SIJ), with associated ligaments and articular structures, including long dorsal sacro-iliac ligament and pubic symphysis.

Active system Major Stabilisers: Glute medius and minimus, multifidus, transverse abdominus and pelvic floor muscles. Prime movers: Glute maximus and medius, latissimus dorsi, thoracolumbar fascia, and lumbar extensors.

SIJ Anatomy – Pelvic Slings The co-contraction of muscles and thoraco-lumbar fascia (TLF) across the Pelvis/SIJ – important for stability.

Posterior Sling -Ipsilateral Glute Max -Contralateral Lat Dorsi -Forces travel across TLF for stability (Vleeming et al., 2012)

www.igof.in/images/art_pelvic12.jpg

SIJ Anatomy – Pelvic Slings Lateral sling

Longitudinal Sling

-Unilateral Gluteus medius and minimus

-Bilateral erector

-Tensor fascia latae and iliotibial band

spinae

-Contralateral adductors (Lee, Vleeming & Jones et al., 2011)

www.physio-pedia.com/File:Lateral_Sling_111.png http://rubyslife.ruby-red.com/wordpress/wpcontent/media/grays-erector-spinae.png

SIJ Anatomy – Thoraco-Lumbar Fascia (TLF) 4 Layers of TLF • Anterior Layer Quadratus lumborum, Psoas • Middle Layer Transversus Abdominus, Internal Oblique • Deep Posterior Layer Transversus Abdominus, Internal Oblique, Multifidus, Erector Spinae, Long Dorsal Ligament, Sacrotuberous Ligament • Superficial Posterior Layer Gluteus Maximus, Lat Dorsi, External Oblique

http://www.netterimages.com/images/vpv/ 000/000/010/10836-0550x0475.jpg

SIJ Anatomy – Thoraco-Lumbar Fascia (TLF) Interesting Pelvis/SIJ facts: • TLF changes over time depending on force applied, (similar to trabeculae in bone formation) - thickest in places of largest forces. • Long dorsal ligament attaches to lumbar ES and multi via TLF, and also to hamstring in some people. ?? • Myo-fascial slings are interconnected with ligamentous system especially in lumbo-sacral area. • TrA is larger in females (males have higher iliac crests). • Strain and tension on epidermis has unknown effect on stability (Rocktape). • Pelvic girdle belt decreased EMG muscle activation of TrA and IO in healthy females. http://www.netterimages.com/images/vpv/ 000/000/010/10836-0550x0475.jpg

Force Closure and Nutation Force closure is the ability of the muscles (including slings) and fascia of the pelvic girdle to actively move the ilium posteriorly on the sacrum.  in turn winding up the pelvic ligaments = Nutation (Vleeming et.al., 2012) This mechanism works consistently throughout gait and single leg standing and weightbearing.

https://musculoskeletalkey.com/pelvis-3/

Force Closure and Nutation If muscles aren’t strong enough or activating efficiently, this can lead the ilium to move anteriorly on the sacrum (counternutation).  stresses the long dorsal ligament over time, and causes muscle bracing (Vleeming et al., 2012)

https://clinicalgate.com/pelvis-3/

SIJ Instability Joint Stability: “The effective accommodation of the joints to each specific load demand through an adequately tailored joint compression, as a function of gravity, coordinated muscle and ligament forces, to produce effective joint reaction forces under changing conditions. Optimal stability is achieved when the balance between performance (the level of stability) and effort is optimized to economize the use of energy. Non‐optimal joint stability implicates altered laxity/stiffness values leading to increased joint translations resulting in a new joint position and/or exaggerated/reduced joint compression, with a disturbed performance/effort ratio.” (Vleeming A, Albert H B, van der Helm F C T, Lee D, Ostgaard H C, Stuge B, Sturesson B)

SIJ Instability • Anterior/Superior movement of the innominate on the Sacrum (Uncontrolled Counter‐nutation). • Puts direct stretch on the Long Dorsal Ligament (Proprioceptive function). • Pain referral pattern in the buttock, down the leg posteriorly and/or laterally up to the foot (usually no neurological symptoms). • Can feel like Low Back or Hip Pain (especially in pregnant women).

SIJ Pathology – Pelvic Girdle Pain • Sacro‐iliac Joint (SIJ) dysfunction (or a reduction in force closure) – leads to: • Muscle cramping/bracing – gluteal attachments, erector spinae and quadratus lumborum • Strain of long dorsal ligament over time • Or pubic symphysis separation/inflammation (due to shearing forces from instability) • Common in pregnant women – more likely with unilateral SIJ instability (due to presence of relaxin hormone, leading to greater joint and ligament laxity around the pelvis)

SIJ Pathology – Osteitis pubis/adductor tendonopathy • Osteitis pubis is an umbrella term for longstanding exercise‐related groin pain, usually characterised by pubic symphysis irritation. • Diagnoses include adductor tendinopathy, iliopsoas dysfunction, abdominal wall pathologies (e.g. hernias), and pubic bone stress reactions. • The fundamental aetiology is that mechanical overload of the pelvic region causes failure of local tissues. • Usually more than one entity is present. • Contributing factors may include: ‐ Increased adductor and rectus abdominis tone ‐ Poor lumbopelvic stability ‐ Lx/SIJ dysfunction ‐ Decreased hip ROM ‐ Iliopsoas shortening

http://www.beliefnet.com/healthandh ealing/images/BK00034_ma.jpg

SIJ & Biomechanics • All true trunk/lower limb flexion, extension, & rotation comes from 3 levers acting on a stable pelvic platform especially in athletic or dynamic movement (levers = Torso and 2 legs). • Gait retraining (use of upper limb in walking). • ASLR and Gillet’s special tests will assess level of force closure (functional test). • In exercise prescription and treatment start with short levers first.

SIJ & Biomechanics Lifting

Forward Bending or full extension

Nutation of the sacrum Close packed, most stable (Supported by interosseous and sacrotuburous ligament)

Returning from bending

Contraction of glut max and lat dorsi required for force closure

Requires Motor control (Glut max, lat dorsi), hams relaxed

SIJ – Biomechanics in Gait Ipsilateral

Sacral rotation

Contralateral

Close or Open

Toe-off

Anterior Rotation

Contra

Heel-strike to Mid-stance

Posterior Rot, moving to anterior rotation ( due to contra rotation of sacrum)

Ipsi

Requires Motor control (Glut max, Lat dorsi), hams relaxed

Swing phase

Posterior Rot

Ipsi

Mid-stance to foot-off

Posterior Rot, moving to anterior rotation ( due to contra rotation of sacrum)

Contra

Requires Motor control (Glut max, Lat dorsi), hams relaxed

Heel strike

Posterior Rot

Ipsi

Foot-off

Posterior Rot, moving to anterior rotation ( due to contra rotation of sacrum)

Contra

Close packed, most stable

Heel-strike to Midstance

Posterior Rot, moving to anterior rotation ( due to contra rotation of sacrum)

Ipsi

Toe-off

Anterior Rotation

Contra

Requires Motor control (Glut max, Lat dorsi), hams relaxed

Mid-stance to foot-off

Posterior Rot, moving to anterior rotation ( due to contra rotation of sacrum)

Contra

Swing phase

Posterior Rot

Ipsi

Requires Motor control (Glut max, Lat dorsi), hams relaxed

Foot-off

Posterior Rot, moving to anterior rotation ( due to contra rotation of sacrum)

Contra

Heel strike

Posterior Rot

Ipsi

Close packed, most stable

SIJ/Pelvis Assessment

Gillet’s Test • Functional test – assesses force closure during SLS Thumb placement: • PSIS • S2/S3

Gillet’s Test • Ax right side with right SLS • Ax L side with left SLS What to look for: • Posterior movement of SIJ – pelvis moves posterior to sacrum (nutation) • Anterior movement of SIJ – pelvis moves anteriorly on sacrum (counter-nutation) • This tells you whether or not the patient has adequate force closure, but it doesn’t tell you why!

Prone SLR • Test of order of muscle activation across SIJ • “Feel” – multifidus, glutes, hamstrings (ideal order) • Repeat either side

• • •

• • • •

Active Straight Leg Raise Client in supine position Client asked to actively SLR (~20-30cm) Client to rate difficulty: • 0 = impossible • 1 = Extremely difficult • 2 = Difficult • 3 = Moderate • 4 = easy Be aware of any hip hitching or lifting of pelvis off bed. Add bilateral compression for intra-articular component. Add sustained compression for 20-30secs to allow unloading of passive structures (Re-setting neuro). Re-assess difficulty • 5 = Easier

Active Straight Leg Raise Dynamic Force Closure (using MMT – more objective) • Active SLR • Active SLR – Compression (See previous) • Active SLR – Sustained compression (See previous) • Active SLR – TA contraction • Active SLR – Gluteal contraction • Active SLR – Lats/TLF Bilateral • Active SLR – Adductor contraction • Active SLR – Pelvic Floor facilitation • Look for strength changes – guides what you focus on with exercise (Slings etc.)

Example – ASLR with Lat activation

Palpation Posterior • Long Dorsal Ligament • Posterior hip joint • Glute Medius • Gluteus Minimus attachment (greater trochanter)

Anterior • Pubic Symphysis • Pubic Rami • Findings may indicate source of pathology.

Glute Medius Palpation in side lying

Palpation Long Dorsal Ligament • Pain provocation • Must be on the long dorsal ligament • 5 mm each side is not positive test (glut attachments, TLF layers, sacrum etc) • Only requires gentle pressure

https://i.ytimg.com/vi/bSF1eahMoFU/hqdefault.jpg

Addition Pain Provocation Tests Compression test • Aim is to stretch the posterior sacroiliac ligaments and compress the anterior SIJ. • Client in supine position. • Apply pressure is from one iliac crest to the opposite iliac crest. • Pain produced may indicate source of pathology is from SIJ.

Addition Pain Provocation Tests Distraction test • Client in supine. • Posterior and lateral force is applied to both anterior superior iliac spines. • Stretch the anterior sacroiliac ligaments and synovium. • Pain produced may indicate source of pathology is from SIJ.

Addition Pain Provocation Tests Thigh Thrust • Client in supine. • Hip is flexed to 90° and the knee is bent. • Apply posterior shearing stress to the SIJ through the femur. • Excessive adduction of the hip is avoided, as combined flexion and adduction is normally painful.

Addition Pain Provocation Tests Squish/AP shear test • Client in supine. • Apply posterior force through inferior aspect of ASIS. • Note any differences in quality and quantity in movement. • Can indicate unilateral stiffness in SIJ.

Additional Tests – Standing/Sitting Flexion • • • •

Client in standing position Palpate both PSIS Ask client to flex forward Note if one PSIS moves before/further than the other

• Findings can also be compared with sitting flexion where test is repeated with client in sitting position instead • Testing for Unilateral stiffness OR instability

Additional Testing - DRAM • Diastasis of Rectus Abdominal Muscles (especially post-natal) • Assessible via Ultrasound (or assessible by feel – finger widths – less accurate) – assess above and below umbilicus • Supine (crook lie) position – measure at rest, then in small crunch (concentric contraction Rec Ab) • 10mm is normal. >10mm is DRAM – e.g. if measured at 15mm, there is a 5mm DRAM

SIJ – Significant findings and Treatment

Glute Med trigger point MFR

SIJ pain - Diagnosis Underlying cause of SIJ or Pelvic Girdle Pain is SIJ Instability SIJ instability on Ax: Gillet’s Test • Anteriorlising with WB (normally) and/or NWB (unusual, only if very unstable) • Posteriorlising with hip ext. (not often - stiffness) Prone Straight leg raise • Normal activation pattern – Glut with Multifidus, then Hams • Pathological – Hams first, counter-nutates sacrum Active SLR • Effortful or painful • Eases with TA/Lat/Glute activation Other findings: • Palpation of long dorsal lig. Painful • Muscle bracing – glute med (common) • Pain provocation tests +ve

SIJ Pain – Treatment All SIJ Rx highly dependent on cause of the condition - on which sling has the largest effect on stability • Basic stability - TA strength and control • Dynamic control – most common – post sling (Gluteus max, and lat dorsi) – Bridging, hip extension – Hip control

• Activation of gluteal muscles to initiate movement • Reduce SIJ stiffness, usually on the other side – SIJ mobilization

• Must take Lumbar pathology into account

– Lx disc bulge work, with extension based pelvic exercises – Lx facet joint pain, with flexion based pelvic exercises

SIJ Pain – Acute Treatment Anything that brings the sacrum into nutation reduces SIJ pain • Mobilisation into nutation or innominate into posterior rotation • Full range lumbar flexion or extension • Hold-relax stretches/Muscle energy techniques of the hamstrings • To inhibit them from pulling the sacrum into counter-nutation

• Tape across SIJ or into nutation • Traction in the line of the SIJ also helps reduce stretch on the Long Dorsal Ligament Exercises • Bilateral – co-contraction glute max / multifidus, promotes force closure to take long dorsal ligament off stretch

Case Studies

MD Health Student Training and Future Events • Private Facebook Group “MD Health Students” • (please write down your email that is linked to your FB account, we will send out invites to attendees): -

To share parts of tutorials and Full Body Assessment Answer questions/queries from students – learn off each other! Musculoskeletal case studies Articles and research Advertise upcoming MD Health events

MD Health Student Training and Future Events Upcoming Student Seminars in 2018 (Dates TBA): - LBP (Nov) Opportunities for ongoing training at MD Health: - For committed students 2-3hrs per week (late 2nd semester, approaching graduation) - Practice assessment and treatment techniques - tutorials - Exercise prescription including pilates