Mechanical Sacroiliac Joint Pain and Dysfunction
Sacroiliac (SI) joint pain is thought to be involved in 15% of all low back complaints. Symptoms of sacroiliac joint pain include low back pain, gluteal pain, sacral pain, groin pain, or hip pain. The pain is typically worse when walking and standing, with relief while lying down.
A number of other conditions can mimic sacroiliac joint pain. A chiropractor is able to assess the joints, ligaments, and muscles of the lumbar spine and pelvis with a number of strategies to determine whether the SI joint is the source of the pain. More importantly, a chiropractor can rule out more sinister pathology that may be present in the vicinity of the SI joint.
The sacroiliac joints connect the sacrum to both the left and right ilium and serve to transmit force in all planes of motion between the lower limb and the spine. The joint is unique in that it displays different types of cartilage along different portions of the joint surfaces. It is a very stable joint and was once believed to not move at all. Recent literature shows that the joint is able to move 2-3 degrees in the sagittal and transverse planes. To completely understand how the joint transfers force and controls motion, the concept of “form closure” and “force closure” must be understood. These two terms coined by Vleeming and Snijders, two experts in sacroiliac joint mechanics, are fundamental concepts for understanding the sacroiliac joint.
Form Closure vs Force Closure
Form closure, is the passive stability caused by the inherent shape of the joint surface and the ligaments that cross the joint space connecting the sacrum to the ilium.
Force closure is the ability of the muscles surrounding the joint to actively control translation of the joint surfaces. This is achieved mainly through compression of the sacroiliac joint. The deep stabilizing muscles of the lumbar spine and pelvis, namely the transverse abdominis, multifidus, internal oblique, diaphragm, and pelvic floor muscles, create this compression.
Motor control, as it pertains to the sacroiliac joint, is the ability of the brain and nervous system to activate the deep stabilizing muscles of the lumbar spine and pelvis at the correct time to create force closure of the joint. One of the world's leading spine research teams from the University of Queensland (Richardson, Jull, Hodges & Hides) have investigated the timing of these muscles in low back pain patients. They have found that normally, these deep stabilizers should contract before a load reaches the low back/pelvis to prepare the spine for the impending force. During dysfunction, there is a timing delay, or absence of contraction, of these muscles and consequently the spine is not stabilized prior to loading. Motor control of these muscles needs to be retrained!
"Recovery is not spontaneous, so even when pain is relieved, dysfunction continues and pain may return at any time”
The gluteus maximus and biceps femoris (hamstring muscle) have also been shown to be dysfunctional in patients that have SI joint pain. During lower limb tasks, the gluteus maximus is delayed in patients with SI joint pain, and the onset of biceps femoris activation occurs earlier. This gluteal inhibition is a common finding and should be addressed in anybody presenting with SI joint dysfunction.
A comprehensive approach to SI joint pain and its associated dysfunction should involve acute symptomatic relief followed by specific rehabilitative exercises. SI joint dysfunction of insidious nature is often due to a patient not moving properly, and therefore a movement dysfunction should be thoroughly investigated. Movement dysfunctions are best evaluated with a functional movement screen done by a trained physical medicine practitioner (chiropractor, physiotherapist, etc). A functional movement screen evaluates tasks such as a deep squat, hurdle step, single leg squat and many more movements to determine various dysfunctions that often manifest as pain in other areas of the body. While form closure is inherently harder to affect with conservative manual therapy, the joints and ligaments can be treated with spinal manipulation to produce immediate pain relief. Force closure is more amenable to therapeutic care, and may be more responsible for long-term relief from SI joint pain due to the ability to affect motor control. While the deep stabilizers that tend to become inhibited need to be activated, as Stuart McGill would say, the whole “orchestra” of the core needs to be addressed with motor control rehabilitation.
“Isolated muscle activation (i.e. abdominal hollowing to activate transverse abdominis) should never be the goal of care, but rather a full integration of the core, trained in all planes of motion, should be sought”
This includes the deep and superficial lumbo-pelvic musculature, the diaphragm, latissimus dorsi, and gluteal musculature. A treatment protocol of care is listed in Table 2. This is by no means an exhaustive list but rather a template of ideas that should be considered when treating a patient with SI joint pain/dysfunction. Remember the practitioner is not treating a condition, but rather a person, and as such, social, emotional, and behavioral factors need to be addressed as well.
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The SI joint is a common location for dysfunction and subsequent pain. There are many other nearby structures that can mimic SI joint pain and therefore a trained health professional should evaluate this area to determine the source of the pain. Once determined to be of SI joint origin, comprehensive acute care and subsequent rehabilitation can resolve an SI joint dysfunction with limited relapse rates.