SI Joint Eval & Tx Flashcards
1
Q
SI Joint
2 Components
A
- Ilium
- Sacrum
2
Q
Long standing controversy regarding Role of SIJ in LBP:
2 Extreme Views
A
- Largely dismissed functionally 2* to little or no mvmt
- Has important primary mvmts that can be assesed as other jts
3
Q
SIJ
FACTS:
A
- Cannot be considered as any other jt in body
- mvmts= small
- not endowed w/ muscles that execute active mvmts
- Structurally and functionally more comparable to intertarsal jts of foot
- Needs to be both stable and mobile
- Motion occurs via action of mm’s moving adjacent bony structures AND GRF’s
4
Q
2 Unique Roles of the Sacrum
Directions?
2:
A
- Longitudinally
- Transversely
5
Q
2 Unique Roles of the Sacrum
1. Longitudinally
A
- Supports L/S, all long. forces delivered to L/S transmitted to sacrum
6
Q
2 Unique Roles of the Sacrum
2. Transversely
A
- Consitutes post. wall of the pelvis, transmits forces sideways from the VC into the pelvis and vice versa
7
Q
SIJ as a Functional Unit
A
- L5-S1
- SI jts (L and R)
- Symphysis Pubis
- Bones: 2 Innominates; Sacrum
8
Q
Architecture/Morphology of SIJ
A
- Part synovial, part syndesmosis
- Sacral surface cartilage→ largely hyaline, 2-3x thicker than iliac
- Iliac surface cartilage→ mix of mostly hyaline w/ fibrocart.
- Surfs irregular→ vary in lvl congruency
-
Bonnaire’s Tubercle→ on iliac surf of SIJ b/w upper and lower aspects
- pivot point for Nutation/Counternutation
- Sacrum wider dorsally at S1 and wider ventrally @ S3
9
Q
Nutation
A
Occurs as sacrum moves anteriorly and inferiorly while the coccyx moves POST relative to ilium
*coccyx pulled UP
Think “cocking it into place pulling coccyx up”
10
Q
Counternutation
A
Occurs as sacrum moves POST and SUP while the coccyx moves ANT relative to ilium
“pushing Coccxy IN”
11
Q
Nutation/Counternutation Ex.
A
WALKING!
*may be some degree of nutation on one side and counternutation on the other side
12
Q
SIJ
Ligs/Joint Cap
Interosseus Ligament
A
- MOST IMPORTANT ligament of the SIJ
- Lies deep in the narrow recess b/w sacrum and ilium, dorsal to joint cavity
- Functions to strongly bind sacrum TO ilium
13
Q
SIJ Ligs
Post. SI Ligament
A
- Connects intermed and lateral crests of sacrum TO PSIS and post end of inner lip of iliac crest
- Acts in concert w/ interosseus lig to bind sacrum to ilium
- Mostly prevents post flaring or diastasis of the joint
- Longer fibers of lig prevent backward rocking (counternutation) of sacrum
14
Q
SIJ Ligs
Anterior Sacroiliac Lig
A
- Covers ventral (FRONT) aspect of joint
- Transverse fibers running from ala (wings) and ant surf of sacrum to the ant surf of ilium
- Attach’s are of considerable dist beyond the margins of the joint
- encompasses the ant. cap of SIJ
- Binds ilium to sacrum
- Prevents ANT diastasis (flairing) of joint (nutation)
15
Q
Sacrospinous Ligament
A
- “sacro”-sacrum TO “spinous”- ischial spine
- broad orig. from the lat edge BELOW SIJ converging on the ischial spine
- Prevents nutation (forward rocking of sacrum) → remember think cocking coccyx BACK
16
Q
Sacrotuberous ligament
A
-
Orig’s from multiple points on sacrum:
- PSIS
- Transv tubercles of lower sacral segs
- Inf Lat. margin on sacrum
- Broad attach to medial margin of isch tuberosity
- Superf fibers of lig are cont w/ long head of biceps fem tendon
- Prevents nutation of sacrum
17
Q
MM’s affecting SIJ
A
QL
Multifidi and Erectors→ contraction produces nutation of sacrum
Psoas
Iliacus
Glute max
Biceps fem
Rec fem
Adductors
Hip rotators
TA
coccygeus (pelvic floor mm’s)
18
Q
Jt mechs of SIJ
A
- Bony locking mech prevents downward motion of sacrum under BW
- Sacrum set obliquely b/w ilia→ SUP end leans ventrally
- Under vertical loads it tilts forward and downward→ nutates (forward rock) around Bonnaire’s Tub
- Shape of sacrum gives bony opposition to nutation
- Ligs keep mvmts minimal****
19
Q
SIJ Changes across lifespan
A
- 0-10→ highly mobile, jt plane close to vertical
- 10-30→ jt plane becomes oblique
- 40→ osteophytes form, capsule thickens, DJD
- 50-60→ motion DECs
- 60-80→ ankylosis (fusing)
20
Q
Prevalence SIJ Disorders
A
~15% of pts w/ chronic LBP
21
Q
SIJ Disorders
Gender Diffs
A
- Pregnancy→ hypERmobile (Relaxin hormone)
- More accel’d ankylosis in males
- Female SIJ smaller, flatter=> more mobile
- COG and SIJ: Females
- SAME frontal plane
- COG and SIJ: Males
- COG more ventral
22
Q
Diff Dx SIJ
A
Validity of many mech tests questionable
Sx distribution is poor indicator BUT pts w/ SIJ probs typ have no pain above waist
23
Q
Possible historical and Dx Clues for SIJ patho
A
- Trauma→ long axis force thru femur OR direct fall on one isch tub (miss chair)
- Inj inolving twist or asymm motions
- pain rolling side to side
- pain ascend/descend stairs
- WB acts may be provocative
- pregnancy/post-partum
- pain w/ arising from seated pos
- absence of midline lumbar pain w/ buttock pain
24
Q
EXAM for SIJ
clear lumbar spine and hip first
HOW?
A
LOOK @ ALL OTHER SUBGROUPS FIRST:
- Manip?
- Directional pref?
- Instability?
- THEN SI
25
3 tests you should do for SI FIRST!!!
1. SI Compress/Distract
2. Sacral Thrust
3. Thigh Thrust
26
International Ass. for the Study of Pain Dx criteria for Symptomatic SIJ
* Pain present in area of SIJ
* Selective stressing of SIJ by clin provocation that repros pain
* **selective infiltration of the symptomatic SIJ w/ anesthetic completely relieves pain**
27
**Special Tests for SIJ:**
**PROVOCATION TESTS**
**\***Highest **reliability and validity**
* Laslett found these 4 contributed to making dx of SIJ pain and dysf
* Robinson found **reliability** of **pain prov** tests was mod to good while **reliability of palp was poor**
28
**Special Tests for SIJ:**
**PROVOCATION TESTS**
**4:**
1. SI Distraction
2. Thigh Thrust
3. SI Compression
4. Sacral Thrust
29
**Special Tests for SIJ:**
**PROVOCATION TESTS**
**SI Distraction Test**
see pics
30
**Special Tests for SIJ:**
**PROVOCATION TESTS**
**Thigh Thrust**
see pics
31
**Special Tests for SIJ:**
**PROVOCATION TESTS**
**SI Compression Test**
see pics
32
**Special Tests for SIJ:**
**PROVOCATION TESTS**
**Sacral Thrust**
see pics
33
**Laslett's _Clinical Dx Rule_ for SIJ**
**\***Perform **SI Distraction** and **Thigh Thrust tests _FIRST_!!! \*\*\*\***
* Inclusion vs. exclusion **Gaenslen's test did not sig. alter results**
* \*When **all provocation SIJ tests are _NEGATIVE→_ SIJ Patho can be R/O**
* Thigh Thrust→ greatest Sn→ .88 (SnNOUT)
* Distraction→ greatest Sp→ .81 (SpPIN)
* OPTIMUM RULE:
* **perform _distraction_ and _thigh thrust_ FIRST**
**\*NOTE: if _familiar sx's_ not provoked→** cont. w/ remaining tests until a **total of 2 positives found**
34
Special Tests of SIJ: **Mobility/Palpation/Pos Tests**
## Footnote
**What should you know about these?**
In general, _poor reliability and validity_\*\*\*
35
Special Tests of SIJ: **Mobility/Palpation/Pos Tests**
_Support Side_ Stork Test
(\*Stork think standing on one leg like a stork\*\*\*\*)
see pics
**\*NOTE:** relative to other mobility/palpation/pos tests→ **this one had GOOD reliability found w/ _stork test on the support side_**
36
Special Tests of SIJ: **Mobility/Palpation/Pos Tests**
Support Side Stork Test
* **Negative Test:** innominate rotation **POSTERIORLY** (moves caudal) on the **support side** relative to the sacrum OR _stayed relatively neutral_
* \*this test assesses the joint in a _loaded pos._ to det normal stability
* **POSITIVE Test:** innominate rotation **SUPERIORLY** (moves cephalad) on **support side** relative to sacrum
* **Interpretation:** indicates _failure of_ **_self-bracing mech._** to maint. SIJ in ints closed pack pos.
* i.e.→ POSITIVE test is suggestive of **SIJ instability or hypermobility on the stance leg**
37
Special Tests of SIJ: **Mobility/Palpation/Pos Tests**
**Gilet's (Sacral Fixation) Test**
**\***almost same as stork test **but now you palpate PSIS on hip that is flexing up (non-supported side)**
Almost same as **Stork Test,** but palpate PSIS on **same side as the hip that pt is flexing**
Thus, in this case you are assessing **unloaded (NWB) side**
38
Special Tests of SIJ: **Mobility/Palpation/Pos Tests**
## Footnote
**Seated Flexion Test (Piedallu's Sign)**
* Are PSIS lvl @ start w/ pt seated?
* Do they remain lvl as pt flexes forward?
* **IF NOT→** indicative of SI jt imbalanace OR perhaps hypOmobility on 1 side
* \***Magee's Interpretation:** if one PSIS is LOWER in upright sitting then appears HIGHER after forward bend→ **that side is hypOmobile**
39
Gaenslen's Test
SEE LAB NOTES!!!!!
SEE PICS
40
Special Tests of SIJ: **Mobility/Palpation/Pos Tests**
## Footnote
**Supine-to-Sit Test**
**\*MAKE SURE YOU HAVE THEM DO A BRIDGE FIRST TO SET THE PELVIS**
* **Interpretation:**
* If leg on PFL side appears **LONGER in supine** and then **SHORTER in long-sitting→** Innominate on that side= **Anteriorly rotated\*\*\***
* If leg on PFL side appears **SHORTER in supine** and then **LONGER in long-sitting→** Innominate on that side=**Posteriorly rotated\*\*\***
41
Special Tests of SIJ: **Mobility/Palpation/Pos Tests**
## Footnote
**Palpation of PSIS, ASIS, Iliac Crest Hts**
* **Interpretation of findings on PFL Side:**
* **PSIS HIGHER, Iliac crest HIGHER, ASIS LOWER=\>** ANT rotated innominate on PFL side
* **PSIS LOWER, ASIS HIGHER=\>** POST rotated innominate on PFL side
***NOTE:** _Pelvic Asymmetry_: No meaningful assoc. w/ back pain\*\*\**
42
**Interventions for SIJ Dysf.**
**Directional Preference Ex.**
**\*if they have one…**
* Force transmitted to the SIJ via **trunk or LE motions**
* Hip flex vs. hip ext.
* **Lunges w/ R vs. L LE ant (in front, like a split lunge)**
* May have to alter **hip IR or ER**
43
**Interventions for SIJ Dysf.**
**Muscle Energy Techniques\*\*\*\***
***First determine direction of innominate rotation***
Anteriorly Rotated Innom.
* **IF proble is _ANTERIORLY rotated innominate:_**
* GOAL= correct it by POSTERIORLY rotating it
* SKTC on affected side
* foot UP on table/chair (affected side foot UP)
* lunging w/ involved side forward
* **MM Energy Techs** using the **hip ext's→** ISO. contraction of hip ext's generates POST ROT. moment on innominate
* bc EXT's pull pelvis POST
* \***majority of pts w/ SIJ probs respond to tx involving _post rotation forces on innominate_**
44
**Interventions for SIJ Dysf.**
**Muscle Energy Techniques\*\*\*\***
***First determine direction of innominate rotation***
Posteriorly Rotated Innominate
* **IF problem is a _POSTERIORLY Rotated Innominate:_**
* GOAL= correct it by _ANTERIORLY rotating innominate_
* Stretching into HIP EXT (on affected side)
* Lunging w/ **involved side BACK**
* **MM Energy Techs→ ISO. contraction of HIP FLEXORS**
* ISO contract of hip flexors generates ANT. ROT. moment on innominate
* bc these mm's pull pelvis ANTERIORLY
45
**Interventions for SIJ Dysf.**
**Muscle Energy Techniques\*\*\*\***
***First determine direction of innominate rotation***
***3 other ways if its _both sides rotated diff directions_***
1. Ant/Post rotation via **resisted hip flex/ext in _hooklying_**
2. End range Ant/Post rotation via **resisted hip flex/ext**
3. **Pubic Shotgun**
1. pt in **hooklying**
2. PT briefly and firmly resists hip ABD (B/L) 3x
1. 1st w/ knees close together
2. 2nd w/ knees slight apart
3. 3rd knees more wide apart
3. NEXT.. PT repos's hands to **resist ADD (B/L) of hips**
1. as pt ADD's, PT pushes OUTWARDLY into ABD w/ a **quick thrust**
2. **\*\*\* SEE LAB NOTES!!!**
46
Special Tests of SIJ: **Mobility/Palpation/Pos Tests**
## Footnote
**Gentle Mob. Tech's aka Iliac Rocking**
1. **STM→** Sacrotuberous lig
1. palp **inf lat angle of sacrum** off the **coccyx** and the **isch tub- lig is ½ way b/w these two**
2. **mobilize into rolling motion about 1min**
2. **Stab. Belts**
3. **Lumbopelvic Stab. Ex Program**
1. TA, Pelvic Floor
2. \***we want them to work in the “new corrected" pos.**
4. Bridging w/ _alternating_ **hip ADD or ABD stab. ex.**
47
In general
## Footnote
**If innominate is ANT ROTATED…**
You want to STRETCH the Hip EXT's OR ISO contraction of HIP EXTs
48
In General,
## Footnote
**If Innominate is POSTERIORLY ROTATED**
You want to STRETCH hip flexors OR ISO contraction of Hip flexors
