1. Sacroiliac Joint Pain and Dysfunction

2. Source of LBP SIJ source of LBP 15-38% of cases
In a 2010 study the cause of subjects with SIJ was: Idiopathic: 30%, Overload of work injury: 26% Fall: 24%, MVA: 9%, Other incidents: 11%
Also includes Pelvic Girdle Pain. Approx 20% of pregnant women in large cohort studies.

3. Integrated model of function
SIJ dysfunction as a failure of load transfer causing pain at joint.
TrA, pelvic floor, posterior sling (force closure)

4. Differential Diagnosis
SIJ pain can refer into buttock, iliac crest, groin, abdomen, leg and foot.
Possible dysfunction or pain from lumbar intervertebral discs or facet joints.
Fortin et al (1994, 2003): potential pain distribution along sciatic nerve mimics a herniated lumbar disc
Screen hip condtions, neuro, as required
Rule out other conditions if only mm trigger point referring pain

5. International Association for Study of Pain
For a complete Dx of pain of SIJ origin:
Pain in SIJ region,
Pain reproduced by clinical tests selectively stressing the joint
Pain completely relieved by selective delivery of local anaesthetic.

6. History, characteristics of SIJ pain
Pain maps: never above L5, may refer down leg
Patients may describe as sciatica
Pain is recurring, triggered by bending, lifting
Commonly idiopathic
Initial episodes and MOI: pregnancy, trauma from fall or MVA, hard braking, transverse force on pelvis
Worse when loaded, eg standing, walking
Possible changes in bladder habits

7. Mitchell et al (2012) clinical review
SIJ is more likely the source of pain if: a) The patient points to the PSIS as the source of pain. b) Pain is predominantly below the L5 level c) The sacral sulcus is tender.

8. SIJ as origin of pain
(Diagnostic anaesthetic injection is reference standard)
Van der Wurf (2006):
All subjects that responded to the SI joint block had symptoms located at the Fortin area (3cm medially by 10 cm vertically inferior to the PSIS)
All subjects that did NOT respond to the SI joint block had symptoms at the Tuber area (just inferolateral to the ischial tuberosity)
Pain in the Fortin area but not Tuber, patients may have SIJ pain
But if they have pain in the Tuber but not the Fortin area it can rule out SIJ pain (sensitive)

9. Clinical tests for Dx pain and instability
SIJ provocation tests:
Sacral thrust
Compression
Distraction
Thigh thrust
Gaenslan’s test
ASLR (has high sens and spec)
Passive joint glide of ilium.
Stork test

10. Laslett et al. (2005)
3/6 +ve provocation tests had Sens: 94%, Spec: 78% for diagnosing SIJ pain.
If Gaenslan’s test is excluded, 2/4 +ve tests Sens: 88%, Spec 78%
In order of highest individual sens and spec:
Thigh thrust
Distraction
Compression
Sacral thrust
Rule out SIJ if all tests do not provoke pain

11. Hancock et al. (2007)
Tests for LBP as disc, facet joint or SIJ as source
Changes and degeneration on MRI increased probability of disc as source. (+LR approx 1-5 for each feature on MRI)
Centralisation of pain increases likelihood of disc as source (+LR=2.8 (95% CI )
Helps rule out disc in absence of these signs
No tests for facet joint were informative

12. Laslett (2008). Clinical Prediction Rule
SIJCPR: Chronic LBP populations with:
3+ SIJ provocation tests +ve
Symptoms that cannot be made to centralise
have a 77% probability for SIJ pain.
If also pregnant, probability increased to 89%

13. Other common associated impairments
Weak core
Weak glutes
Tight or previously injured hip and back muscles
Malalignments
Leg length discrepancies

14. Leg length discrepancies
Causes pelvic obliquity
Kiapour et al. (2012), relationship between LLD of 1, 2 and 3 cm.
1cm increases load of SIJ up to 5x, 3cm up to 12x

15. Malalignments Innominate shears, sup and inferior
Innominate rotations, anterior and post
Innominate in flare and out flare
Sacral torsions, flex and ext
Unilateral sacral lesions, flex and ext.

16. Riddle and Freburger (2002)

17. Stork test – Muscle activity
Barbara Hungerford (2003, 2004) hip flexion in standing EMG acitvity:
Subjects with no hx of pain (control): Feedfoward activation of OI, lumbar multifidus. Biceps fem, add longus, glutes, TFL after initiation of motion.
Subjects with PGP: Onset of OI, multifidus and glute max significantly delayed on symptomatic side Biceps fem activation significantly earlier

18. Stork test - Innominate motion
Control subjects: Posterior rotation of innominate (sacral nutation). Self bracing mechanism
PGP group subjects: Anterior rotation of innominate (sacral counternutation). Failure of self bracing mechanism.

19. Stork test – Intratherapist reliability
Hungerford et al. (2007)
3pt scale: PSIS neutral/ cephalad/caudad direction
2pt scale: -ve= neutral or caudad. +ve= cephalad
33 subjects, 3 therapists
Good inter-rater reliability for 2pt scale. Agreement between therapists occurred: 91.9% (L), 89.9% (R)
Moderate reliability for 3pt scale: 82.8%(L), 79.8%(R)

20. Physiotherapeutic treatments for SIJ pain
Address entire abdomino-lumbo-sacro-pelvic-hip complex.
Correct malalignments of pelvis and spine + address any deficiencies and restrictions found in PE
Muscle energy technique and taping
Myofascial release and dry needling of trigger points
Exs for stablisation, muscle activation and targeting weak links + imbalances.
TrA and the multifidus may increase tension on posterior SI ligaments and posterior layer of the thoracolumbar fascia, hence causing a nutation force on the sacrum

22. Allison et al. (2008)
Feedfoward responses of TrA are directionally specific and act asymmetrically
TrA is a feedfoward muscle and preactivates other trunk mm during rapid arm raising.
The ipsilateral TrA lagged behind that of the contralateral side
Contradicts earlier studies stating the bilateral feedfoward responses are highly consistent in healthy controls and how this isolated activation contributes substantially to segmental stability of the lumbar spine.

23. Gnat et al.(2012)
An in vitro study found a simulated TrA muscle force does not increase stiffness of the pubic symphisis or innominate bone.
Supports the notion that TrA’s role in stabilising the SIJ is via tensioning of the thoracolumbar fascia

24. Cusi (2010) clinical review
Differentiate primarily force closure and form closure failure through exclusion
Exs programs successful if adequate ligamentous strength (form closure)
Up to 3 months to yield results

25. Stuge et al. (2004) RCT Post partum women with PGP
Physio with stabilisation exs vs. Physio alone with basic strengthening/mob exs
Exs 30-60min, 3x/week for weeks.
50% reduction in disability, 30mm reduction in pain VAS scale, improvement in QoL at 1 year cf. insignificant changes in control group.
Maintained at 2 yr follow-up

26. 3 Stages of Exercise Therapy
Isolation
Train motor control ability TrA, pelvic floor +downtrain global mm. compensation
Combination
Progressively challenge, incorporate activation of global mm. while maintaining control from prev stage.
Function
Progress to functional activities according to patient needs and goals.

27. Fail to respond to exs program?
Intrinsic factors:
Poor design (exs not specific enough)
Premature progression through stages
Poor compliance
Poor exs technique
Extrinsic factor: failure of form closure if program was executed correctly.

28. Prolotherapy
Stimulate proliferation of collagen for tissue repair of weak SI ligaments
Poor evidence in earlier studies due to specific cause of LBP unidentified. Stiffness, laxity, mm weakness, SIJ, facet joint, disc?

29. Prolotherapy studies
Cusi et al. (2008) SIJ Case series 25 patients not responding to exs
3 prolotherapy injections, 6wks apart into dorsal interosseus lig
Significant improvement in clinical exam paramters and functional questionnaires at 3, 12, 24 months.
Mitchell et al case series: prolotherapy on SIJ ligaments resulted in 76% of patients satisfied.
Kim et al. (2010) RCT: ““Intra-articular prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections.”

30. Pelvic Compression Belt
Jung et al. (2012)
Pelvic compression belt improved hip extension muscle activation in SIJ patients during SLS.
SIJ pain group with pelvic belt: sig decrease in biceps fem activation when compared to control
+Premotor reaction time for glute max decreased and increased for biceps fem.

31. Posterior pelvic tilt taping: Lee and Yoo (2011)
Case report: 20 yr old female swimmer with anterior pelvic tilt and hyperlordosis. Chronic bilateral SIJ pain.
PPTT performed 6x/week. Avg of 9hr each time for 2 weeks.
Cobb's angle (L1-S1) had decreased from 68° to 47° and that the sacral horizontal angle had decreased from 45° to 31°.
Reductions in motion asymmetry, provocation test pain and pain on palpation of medial buttock area.
No follow up

33. Spinal and SIJ HVLA Manipulations
Kamali and Shokri (2011): single session HVLA to SIJ vs. HVLA to SIJ and Lumbar spine (rotational)
16 subjects each group, diagnosed with SIJ pain with provocation tests
Both groups significant improvement in pain and function immediately, 48hr and one month post
SIJ and lumbar manipulation more effective than SIJ manipulation alone
Treat both as closely interrelated

34. Corticosteroid injections
Limited evidence
Case series report excellent pain relief with duration up to 10 months
77% of 155 patients positive responders over a mean: followup of 44 months, 2.7 injections, duraction of 9.3 months

35. Hansen et al. (2012)
Sys review on SIJ interventions for pain relief (11 studies)
Evidence for cooled radiofrequency neurotomy in managing sacroiliac joint pain is fair.
Evidence for effectiveness of intraarticular steroid injections is limited (or poor).
Evidence for periarticular injections of local anesthetic and steroid or botulinum toxin is limited (or poor).
 Evidence for effectiveness of conventional radiofrequency neurotomy is limited (or poor).
Evidence for pulsed radiofrequency is limited (or poor).

36. THE END.