The SIJ - Southern Health NHS Foundation Trust

The SIJ
Dr Neil Langridge MSc MMACP BSc (Hons)
Consultant Physiotherapist
Specialist manual therapist
DOES IT MOVE TOO
MUCH?
IS THERE A LACK OF
MOVEMENT?
ANATOMY
Bio-mechanics have been recognised
since 17th century.
•Hippocrates era recorded an interest in
the pelvic floor.
•Synovial joint which is L-shaped.
•Ilial side = FIBRO cartilaginous
•Sacral = HYALINE
Locking mechanism
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Due to the ridges in the joint surfaces.
Due to the loading capacity of the joint.
Due to the force closure of the musculature.
Due to the control and support of the ligaments
SPJ
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Cartilaginous joint
Can be a source of pain
PPPP
Symphysis pubis dysfunction
Anatomy
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Supported by capsule, blood vessels and collagen.
Overlying support via ligaments and muscle.
SIJ richly innervated by nociceptors.
Nerve endings terminate in capsule and ligaments.
Innervation is via post primary Rami L4-S3 Posteriorly/ant primary rami L2-S3 anteriorly.
Close relationship between SIJ and neural structures i.e lumbrosacral nerves.
Capsular stim=buttock,groin,thich,calf,foot. lThe ligaments are very strong and are innervated.
Pain generating .
• Sacroiliac, long dorsal, sacrotuberous,iliolumbar,sacrospinal, ventral.
Long Dorsal Ligament
• PSIS-3/4 transverse tubercles. Can
be palpated just below PSIS. Very
commonly pain generating.
• Resists counter nutation (extension
of sacrum)
Sacrotuberous Ligament
• Pos border ilium,sacrum,
coccyxischial tuberosity
• Can be palpated with dysfunction
• Resists nutation (flexion of sacrum)
• Major muscle attachment.
Iliolumbar ligaments
• Transverse processes L4,5 –iliac
crest.
• Lead to iliac pain
Sacrospinal ligaments
• Lower sacral and upper coccyx –
ischial spine
• Mimic coccyx pain
Coccyx pain
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Neuropathic
Capsular
Joint articulation
Yellow flags
Ventral Ligaments
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Baers Point
Groin pain
Thicker in females
Fabers test
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Inflammatory arthropathy
AS
MRI - inflammatory changes
OA hip
Nutation
• Nutation - normal physiological mvt.
• Sacrum rolls forward between the ilia.
• Occurs bilaterally -supine lying to
standing, and increases during initial
stages of lumbar flexion until checked
by sacrotuberous
Counter Nutation
• Sacrum rolls back between the ilia .Moving
in the vertical and horizontal planes.
• Occurs when lying supine with a flat Lx.
• Limit of lumbar flexion.
• Unilateral rotation occurs with lower limb
extension.
• Limited by MF LDL.
Ilial Rotation
• Anterior rotation is the position of
instability and of dysfunction
(Tigny 1995).
• Need to “relocate posterior
rotation”
• Arms of motion
• Short and long
• Need to test these in a manual
therapy approach.
Axis – Manual therapy
lumbar apex
short lever
medium lever
long lever
Role
• SIJ transfer loads. Well made in supporting compressive loads.
• Articular motion 1-4 degrees (Struesson et al 1989)
• Notable differences found in stiffness values with symptomatic,
asymptomatic (Buyruk et al 1997).
• STABILITY
• Injury to a joint can increase the range of movement and so lead to laxity.
• Conversely restrictions in physiological processes can lead to relative stiffness
Panjabi – “feel of movement”
Force Closure
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Vleeming et al 1990.
Force closure is provided by the inner unit, Tra, MF, PF.
Outer sling - Obliques, adductors=ant.
Lat dorsi, Glut max=pos.
Biceps femoris (sacrotuberous lig) =lat
Altered patterns of recruitment in patients with SIJ pain (O’Sullivan et al
2002).
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A= fascia of glut max.
B= fascia of glut med.
C= fascia of ext ob.
D= fascia of lat dorsi.
1= PSIS.
2= Sacral Crest.
LR= Lateral Raphe.
Composed of 3 layers.
Key element in the transmission of forces.
lCreates stability and allows load transfer.
• In long term rehabilitation all muscles that
attach to the fascia can help in creating an
optimum environment for recovery.
• Tends to be poor in research
• Evaluates quality, stability and
movement
Pain provocation
Motion testing
• Quality
• Motion
• End feel
Positional testing/evaluation
ASLR
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Mens et al (2002)
Slings
Motion control
Loading
ASLE
• Evaluate the extension motion
• Pain provocation testing-Maigne etal 1996 noted that individual testing is not enogh
to support validity.
• lLaslett and Williams found acceptable validity with 5 tests as did Kokmeyer 2002.
• lPalpation- poor inter tester reliability but good intra-tester. We are inconsistent
from palpating opposite sides.
• lNo studies to support or refute positional palpation (Haas 1991).
• lO’Hare& Gibbons (2000) some measure of self consistency.
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Gillets test-little diagnostic use Dreyfuss et al (1996).
No support for forward flexion test.
Some predictive value with a cluster of tests Cibulka & Koldehoff (1999).
ASLR Mens et al 1999.
Core stability- TRa decreases SIJ laxity Richardson et al (2002).
Alterations in muscle activity Hungerford (2003).
Subjective
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Normally trauma.
Pain not below the knee (unless altering mechanics at L5/S1.
Pain over the PSIS. (Reliable in finding pain).
Single leg activities.
Mid flexion pain.
Groin,buttock,symphysis pubis pain.
• Assess lumbar spine and hip.
• Do expect restricted movements of the hip,LX l Observation (ASIS,PSIS.) l
Pain provocation tests.
• Movement tests.
• Accessory movements.
• Muscle assessment
Treatment
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Mobilise or manipulate the stiff segments.
Inner unit stabilisation exercises.
Global muscle balance.
SIJ belts.
Conclusion
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Eliminate hip
Movement tests
Pain provocation
Articular tests
Muscle function
Treat