Sacroiliac Joint Dysfunction

Low back pain is fairly common. Successful eradication of low back pain requires an accurate diagnosis of the underlying source of that pain.  Numerous anatomic structures may be the source of pain due to injury or degeneration (wear and tear or overuse).  There are joints, ligaments, muscles and tendons and nerves interacting, moving and where there is expected normal function, there exists the potential for dysfunction.  Identifying the source of dysfunction becomes a challenge in a smaller targeted area when the symptoms are vague, or when symptoms have existed for a longer period of time.  Older, longer lasting pain and dysfunction promote the potential for multiple existing problems contributing to a clinical scenario of low back pain.  But it is very common for people with low back pain to experience mild symptoms initially, and wait a while before actively seeking to correct for them. 

If this is pain pattern is familiar read on:

 
 

 

Unilateral sacroiliac (SIJ) pain pattern. Pain coming from the sacroiliac joint is usually centered over the area of the posterior superior iliac spine (PSIS), with tenderness directly over the PSIS. Lower lumbar pain occurs in 72% of cases; it rarely presents as upper lumbar pain above L5 (6%). It may radiate over the buttocks (94%), down the posterior–lateral thigh (50%), and even past the knee to the ankle (14%) and lateral foot (8%). The affected individual may report abdominal (2%), groin or pubic (14%), or anterior thigh pain (10%).

 

 

 

 

 

 

 

 

One of the less common sources of low back pain, but often left untreated until it has become quite chronic is the sacroiliac joint.  

The sacrum is a wedged shaped bone that provides resistance to both horizontal and vertical shear forces.  The SIJ is a diathrodial joint that contains synovial fluid.  The joint surfaces are different than the other joints in the body. Hyaline cartilage is available on the sacral surface and this surface is flat. The iliac surface is covered with a rough fibrocartilage.  Strong ligamentous structures support the SIJ. Ligamentous structures are effective in creating resistance to shear. The joints are surrounded by some of the most powerful muscles of the body, but none of these have direct influence on joint motion.  The main function within the pelvic girdle is to provide shock absorption for the spine and to transmit forces between the upper body and the lower limbs.

 

 
 
 














Sacroiliac joint (SIJ) pain does not usually present with an acute injury. Ligamentous degeneration, weakness, or recurrent exposure to lower energy trauma are the major causes of SIJ dysfunction. Female hormones are released during pregnancy, relaxing the sacroiliac ligaments. This stretching in ligaments results in changes to the sacroiliac joints, making them hypermobile and this is a common cause of SIJ dysfunction. The sensation of discomfort or pain often begins slowly, with pain radiating down one leg or on one side of the lower back. And much of the time those who experience SI joint pain are using good form when they exercise. Yet pain is present during back extension, squatting, abdominal work, basically pain no matter what they’re doing.   The classic symptoms include pain in the low back, buttock, pelvis ,hips and groin. Pain may radiate up into the middle back.  Pain may be experienced only on one side if only a single joint is affected.  There may be pain on arising from sitting, or  pain with sitting.   There may be the sensation of numbness, weakness, difficulty bearing the weight of your body on one of your legs or the feeling that your leg might buckle out from under you.  The pain of  SIJ dysfunction is usually worse in the morning  and then eases over the day.  These symptoms are similar to most other sources of low back pain so make diagnosing a SIJ dysfunction difficult.  Imaging studies can rule out many of the other sources of possible pathology.  A skilled clinician can identify SIJ dysfunction by performing provocative tests in a thorough physical examination.


To really resolve SI joint dysfunction one has to restore fluid mobility to all the low lumbar and pelvic joints.  Take a moment to re-evaluate your usual patterns of motion, whether these be daily activities or exercise.  Try the simple spine range of motion exercises delineated below and identify those planes of motion that are limited.  Take note of the asymmetries in the way your body moves.  One does not need the flexibility of a contortionist but symmetry is important as is functional strength.
Functional strength is that strength and endurance you require to perform those activities included in your usual schedule.    We do not realize areas of inflexibility and weakness that develop, and we compensate for those using poor body mechanics and we accept these until we note pain, and until that pain interferes with our functioning. 

 

Now back to resolving SIJ dysfunction, the first key to success, as one rehabilitates is to make sure you are working within your limits.  The next most important variable to successful rehabilitation of SIJ dysfunction is moving what’s not moving, and adding more variety of movement to your repertoire.  Now combining the two, limit yourself to move within your present capabilities in all planes of motion.  If you feel any pain in any movement, it’s beyond your current limitations.  Moving exclusively in a single plane is limiting and makes us prone to overuse.  The spine is intended to flex, extend, rotate, and laterally flex. Add variety and change the way you move to help gain ranges of motion. 

 

That is it!  Mobilizing the SIJ carefully and strengthening the surrounding structures will restore a healthy joint and the pain will resolve.  Ice and medication may assist the process (acetaminophen or anti-inflammatory drugs like ibuprofen).  There are procedures that a physician might assist you with when SIJ dysfunction is severe.  There are diagnostic and therapeutic injections and surgical procedures for pain and instability.  There are numerous resources available detailing these procedures elsewhere.

  

 

EXERCISES:

Simple spine range of motion:

Side bending



 

 

  

 

 



 

 

Alternating toe touches

 

Forward roll/crunch

  











 



 

Wall bends

 

 



Strengthening :

The lateral lunge

You start in the same position as a forward lunge, standing straight up with your feet shoulder-width apart, arms down at your sides. Take a big step to not quite to the side, more to the diagonal, lunging down and putting most of your weight on your leading leg. Lower yourself down as far as is comfortable for you, always keeping your toes pointing forward during the exercise, lead foot flat on the ground. Return to your starting position, then repeat on the other leg.

Bridges with adduction

*Note – these  exercises are among my favorite being most effective and safe, but these are not the only exercises that will recondition the pelvis and sacral region.

Common Postural Neck Pain

 

Tension at the base of the neck, or maybe you feel it across your shoulders but the sensation is one most of us have experienced; Heavy pressure, squeezing and tightness that translates as pain somewhere in the upper or middle back or shoulder.  Often there is radiation up toward the head or down along one or both arms.  You may feel burning or tingling.  You no longer remember the freedom of fluid soft tissue mobility that once existed among the individual structures in the neck region.  Years ago, each vertebra, both collar bones, each shoulder blade moved on its own without disturbing surrounding structures.  Now, when you tilt your head, or raise an arm, it’s as if half of your chest rises.    

       Everything we do is done in front of us.  We use our arms and our hands and watch with our eyes.  Our heads are usually bent forwards.  Our shoulders are rounded, sitting in front of where they should be.  And once we have finished whatever activity we have just completed, we rarely resume a “proper” posture but maintain this forward rounded one.  Gravity and habit brought us to this shape.  Until we feel pain, we have no stimulus to change.  Unless we happen to catch a glimpse of ourselves in a mirror or a photograph and notice how we actually look so hunched. 

Figure 1

     A main muscle that supports the head in its upright posture is the trapezius ( Fig 2).  When the head is bent forward, the trapezius is in essence turned off.  We then recruit muscles nearby to hold the head up instead.  But these muscles are not intended to do this job.  Their fibers are not oriented to create the upward force needed to support our 14 to 20 pound skulls.  The thin strap muscles that surround the neck twist and turn the head sideways, upwards and downwards.  When we clench these muscles to use them as a head support, they fatigue, their fibers shorten, and their metabolic processes are altered causing a build-up of noxious substances.  The soft tissue surrounding these muscles are altered by the changes in the muscles’ function and the entire area becomes dysfunctional.  The neck area changes shape becoming rounder and thicker.There is less motion, so there is less blood flow with less oxygenation and impaired tissue metabolism.  Eventually we experience discomfort and then pain.
 


Figure 2

Figure 3



The muscles most often affected are the semispinalis, splenius cervicus and capitus and the scalenes, especially the posterior scalene (figure 3).  There is not much motion within the fibers of these muscles, even when they work at their maximum potential. 


When the local environment is healthful, circulation is sufficient to clear any toxic byproducts of normal reactions.  In a setting of chronic, unhealthy behaviors, in the presence of soft tissue damage there is a build up of noxious stimuli.  The local circulation becomes overloaded and cannot clear the area.  The tissue becomes further damaged and scar forms.  The process is self propelled to escalate.  We perceive an increase in pain with no additional obvious cause for  injury.   We develop neck, shoulder and head pain.

Referred pain:

    This is pain felt in a part of the body other than its actual source.  A network of interconnecting sensory nerves supplies many different tissues.  When there is an injury at one place in the network, this pain can be interpreted in the brain to radiate to nerves and can give pain elsewhere in the related areas of the network. If this does not make sense, think of it this was.  Embryologically we start with a single cell that divides into two cells, and then those two into four, those four into eight and so on.  The cells differentiate into all of our different structures, and migrate away from each other to their proper places.  As we get more cells, they take up more space and each are located further away from each other.  But cells that were originally linked maintain some connection despite physical distance, perhaps chemical, perhaps neurological.  When one structure is affected by a stimulus or injury, all related structures may be affected and this is a referred response or referred pain. 

 

      Referred pain is an important component of neck pain and headaches.  Much of the pain experienced is a result of pain referred from original sources of injury.  Treatments need to be directed at the injury and not necessarily at the sites of symptoms.  Treatment should be aimed at restoring healthy tissue.  The best way to achieve this is to restore posture and normal motion to the area.  This will take some time.  To retrain any body takes time and effort. Exercise to strengthen the middle and upper back is a long term solution.  Physical therapies including modalities with soft tissue manipulation, transcutaneous nerve stimulation, ultrasound, the application of ice and heat will promote soft tissue health and healing.  For very focal tissue repair, trigger point injections may help disrupt stubborn tissue damage and then promote muscle tissue repair more rapidly than manual work and exercise alone.  Trigger point injections are performed by a specialty trained physician.  This may be a Physiatrist, Orthopedist, Neurologist or Rheumatologist.  They can be repeated often if necessary, or done once.  The success depends on a number of factors; how long the soft tissue injury has existed, the accuracy of the diagnosis for the trigger point injection, the skill of the clinician. 

 

    The success of therapy will also be dependent on numerous factors.  Therapy requires patient participation.  It is an interactive modality that requires homework.    Our soft tissues (our muscles, nerves, ligaments, tendons) have memory and need to be trained and reminded of the proper positions to hold and the proper ways to move.  We must practice good posture and proper kinetics to maintain them.  If we move our shoulder blades regularly they remain loose.  If not, they become stiff and locked within the back muscles (for example).  But this is an important example, because so many of the muscles that control head and neck motion are attached to the shoulder blades, so if they are not moving freely, the head and neck will feel stiff.  Now, this is not something we wish to think about.  We just want to live, and move, freely, without pain. But, and forgive the cliché, use it or lose it.  It is important that people do not underestimate the importance of some form of “exercise” in their rehabilitation when they have neck pain and/or headaches. 

 

   I have purposely delayed discussing medications as treatment.  There is a list of medications used to treat neck pain.  The pain arises from numerous sources: mechanical, muscular, neurological and centrally mediated – especially once the pain becomes chronic.  Medications should be used to help enable one to endure the pain while participating in the mobilization phase of a rehabilitation program.  For the small percent of people with chronic, incurable conditions, medications are used to manage pain appropriately.   What is an incurable neck condition?  Osteoarthritis, yes.  Herniated disc, no. But even those with osteoarthritis do not necessarily require lifelong medication.  Anti-inflammatory medications treat the pain caused from inflammation.  This is pain induced by tissue damage, when there is underlying tissue disease, whether systemic or induced by strain.  These include ibuprofen (motrin) or naproxsyn(aleve).  Analgesics treat mechanical pain caused by things such as joint disease and degenerative conditions or traumas.  Acetaminophen (Tylenol) is an example.  The best class of medication for muscle pain is the muscle relaxing drug and the most popular is cyclobenzaprine (Flexeril) though the one I like best is tizanidine (xanaflex) since this is less sedating.  Finally drugs used to address central pain, that is pain arising from the central nervous system, what is often called “nerve” pain can be varied.  These medications are a bit more complicated.  They are drugs whose main use are to treat psychiatric and neurologic conditions but also have been shown to also temper pain.  Gabapentin (Neurontin) is a popular example.  I am not suggesting a medication regimen here but only explaining how medications might be used.  Every medication plan would be tailored specifically for any individual based on their specific needs.  And usually patients find medications unsatisfactory in treating their musculoskeletal pain. 

The topic of neck pain is vast.  This article just touches on a small component, specifically common musculoskeletal pain.  And even this topic can be expanded.  But we have to start somewhere.  The take home message, if you have neck pain for more than a couple of weeks, mention it to a physician.  Seek assistance in resolving the issue while it is easy to fix.  Chronic neck pain is much harder to get rid of and can lead to significant debility.  
 

Common Low Back Pain

 Low back pain is so common, yet when it hits people cannot help but worry that they  have a serious problem.  They notice the ache, and their initial reaction is to ignore it, hoping, it will go away.  But the reality they live, an insidious underlying stress that grows daily as the pain persists.  They notice the limp in those first few steps when they stand after sitting for a while, but assume no one else can see it.  Sitting is not what it used to be, once restful, now that nagging pain in the buttock and leg.  Their beds are suddenly uncomfortable.  Walking is ok, for a while, as long as they are not carrying anything, or stopping and starting too often.  But it is nothing, really.

Four to six months later they think maybe something might really be wrong.  Now there is some serious leg pain, at times maybe some tingling or altered sensation in the buttock and or leg.  The middle back aches and feels weak.  They feel tired and grouchy.  They consult a doctor for help with their “sciatica” and after careful evaluation the well-meaning practitioner confirms the diagnosis, or may even, with great concern hearing how long the issue has existed, suggest a more serious issue such as disc disease.   

The pain from true sciatic nerve compression will look like this:

When the sciatic nerve is compressed significantly and the fibers irritated enough that their function becomes compromised, one will experience symptoms along the entire course of the nerve. 

The pain from a disc injury will look like this: One will experience pain in a particular area depending on which disc is affected.  There may be tenderness over the area of the disc initially when a disc is injured but most disc injuries heal over 6 weeks (approximately). 

More common than these, people experience pain from gluteal strain.  The gluteal muscle that sends pain to the leg is the gluteus minimus and pain from gluteus minimus strain looks like this:   

Now at four to six months, one thinks, sure, I have that pain, but I have so much more than that.  My ENTIRE BACK aches.  There is sharp, stabbing pain that could not possibly be the result of simple butt sprain. 

And sometimes, that is the case.  

Thankfully, it is not usually the case.  A good majority of low back pain is muscle pain.  There are more muscles involved than just gluteus minimus.  Gluteus maximus, gluteus medius and quadratus lumborum account for a significant percent of back pain.

Gluteus Maximus Pain:

 

Gluteus medius pain:

  

Quadratus lumborum pain:

These are the usual suspects, though there are a few more but no need to overwhelm you with details.  The point is to understand that pain originates from numerous structures.  Your healthcare practitioner will recognize the pattern of the pain, the quality of the pain and your functional deficits and from these identify what has been injured.  And yes, it is important to make sure there is no nerve, disc or bone damage because these, left unrecognized can result in serious consequence.  But the major source of low back pain is some injury to the soft tissue structures, the muscles, their tendons, ligaments or the surrounding support tissues. 

Lower back pain that lasts for more than two weeks can lead to muscle weakness (since using the muscles hurts, the tendency is to avoid using them). This process leads to disuse atrophy (muscle wasting), and subsequent weakening, which in turn causes more back pain because the muscles of the back are less able to help hold up the spine. This is another reason why more than one single area feels pain.  Beyond the original strain or injury, additional structures become affected and become symptomatic.  It is wise to acknowledge any persistent ache or pain that exists for longer than a few days. 

 

The initial treatment for any pain in the back is to rest the injured structure.  48 hours should be sufficient to allow recuperation for any mild overuse.  If pain persists after this, there is most likely some degree of true injury.  Next gentle use, and not stretch is the best way to rehabilitate an injured structure.  The goal is to allow ample blood flow to injured tissue to enhance the healing of injury without adding to any strain or tissue damage.  In physical therapy terms, this is known as therapeutic exercise and it entails movements that include simple exertions, usually much more simple than any functional motions involve; something as simple as contracting and relaxing a muscle a few times with rest periods in between, for example.  Once the symptoms are diminished you can advance to trying more functional motions and exercises.

You will find an abundance of therapeutic exercises available to help relieve low back pain.  There is no single right one.  The best depends on your particular problem and your specific abilities (flexibilities, coordination and strengths).  But exercise of some form is usually the best cure.  The back requires motion. 

Physicians will suggest diagnostic tests as needed to ensure your safety.  They will prescribe medications to temper your pain and prevent subsequent injuries to the rest of your body, to keep you moving as normally as possible and prevent overall deconditioning.  The ultimate goal is always to identify the specific cause of the pain, target a therapeutic program that will restore normal motion as quickly as possible to enhance healing.