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.