Sacroiliac Joint Stability An Orthopedic and Pelvic Health Approach to Dysfunction



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Sacroiliac Joint Stability

An Orthopedic and Pelvic Health Approach to Dysfunction

Illinois Physical Therapy Association

Revitalize 2017
Thomas Dillon, PT, DPT

Teri Elliott-Burke, PT, MHS, WCS, PRPC, BCB-PMD

Sacroiliac joint (SIJ) pain can be a challenge to evaluate and treat. Traditionally the SIJ has been evaluated with pain provocation tests. Increasingly studies are focusing on the evaluation of the stability of the joint. This program provides an overview of SI anatomy, stability theories, and related pelvic girdle components including the pelvic floor musculature. Techniques for the evaluation and treatment of SI stability will be presented and practiced.

Course Objectives

1. Participants will describe the interaction of anatomical structures involving the sacroiliac joint.

2. Participants will describe and perform 3 evaluative measures for structures relates to sacroiliac joint stability.

3. Participants will describe and perform 3 treatment techniques to address sacroiliac joint stability deficits.



4. Participants will identify common dysfunctional patterns present in people with sacroiliac stability conditions.

  1. General Anatomy Overview

  1. Lumbopelvic-Hip Complex: Today focuses on muscle structures in relation to SI stability.

    1. Latissimus dorsi and erector spinae (Pardehshenas, 2013)

    2. Quadratus Lumborum, Hamstrings, Multifidus (Vleeming, 2012)

    3. Hamstring connection to STL

    4. Transversus abdominis, internal oblique (Vlemming, 2012; Hungerford 2003)

    5. Gluteus Maximus (Vleeming, 2012; Hungerford 2003)

    6. Gluteus Medius (Don Tigney, 2011)



  1. Pelvic Floor: Three Layers

    1. Function of the pelvic floor: Support, sphincteric, sexual appreciation, stability

    2. First Layer – bulbocavernosis (bulbospongiosis), ischiocavernosis, superficial transverse perineal

    3. Second layer- sphincter urethra vaginalis, compressor urethra, external urethral sphincter, deep transverse perineal

    4. Third Layer – levator ani, Pubococcygeus, Iliococcygeus

    5. Obturator internus



  1. SIJ Stability Theories (Normal Presentation)

  1. Load Transfer Theory

    1. The primary function of the lumbopelvic-hip complex is to transfer loads safely while fulfilling the movement and control requirements of any tasks (Lee, 2011).

    2. Bipedal posture in humans requires greater resistance to gravity. In the upright posture increased lumbopelvic compressional forces are necessary for stability (Vleeming, 2012).



  1. Form/Force Closure Theory

    1. Form closure: A stable situation where no extra forces are needed to maintain the state of the system (Snijders, et al 1993), as well as ability to resist shear or translation when loaded (Lee, )

      1. Configuration of interfacing joint surfaces and “wedging” of sacrum into ilia, along with ridges and grooves of the surfaces themselves (Vleeming, 2012).

    2. Force Closure: extra forces needed to keep the object in place (Snijders, et al 1993)

      1. Nutation of sacrum will tighten SIJ ligaments to prepare for increased loading (Vleeming, 2012).

      2. Muscles noted above

        • Deep muscles of the lumbopelvic increase the stiffness of the SIJ. These muscles include transverse abdominis, multifidus, and the pelvic floor. Stiffness augmented by superficial muscles external and internal oblique, rectus abdominis, and erector spinae. (Richardson et al 2002)

        • Unilateral versus Contralateral loading: (Vleeming 2012, Hamed 2013)

          • “cross-bracing” (Vleeming 2012)



  1. Canister theory

    1. Diaphragm, inter abdominal and thoracic pressure, pelvic floor (Beales, 2009, Lee, 2012)

    2. A soda-pop, three-dimensional model for trunk muscle support for breathing and postural control. Vocal folds to the pelvic floor. A breach in pressure anywhere along the cylinder will impair the total function (Massery, 2012)



  1. Dysfunctional Muscle Patterns

  1. Asymmetrical forces act on joint/Unilateral pull (Vleeming, 2012)



  1. Double/Single Leg with Load in Hand:

    1. Two-legged standing with weight in dominate hand

    2. One-leg stand with weight in ipsilateral side (Pardehshenas, 2014)

    3. One-leg stand with weight in contralateral side (Pardehshenas, 2014 )



  1. Gluteus Musculature

    1. Over activation and weakness of Glute Max (Vleeming 2012), delayed onset (Hungerford, 2003)

    2. Cross-Bracing (Vleeming, 2012)

    3. Inhibition of Glute Med (DonTigny, 2011)



  1. Pelvic Floor (Vleeming, 2012).



  1. SI rotation (Illium on sacrum) Asymmetries (Vleeming 2012, Hungerford, 2003)

    1. Ant rotation or innominate and/or relative counternutation of sacrum (Lee 2011)

    2. Ant rotation loosens STL (DonTigny, 2011)



  1. Evaluation of SIJ Dysfunction (Lab and lecture)

A. Tests/Measures

a. Clinic objective measures, special tests



        1. ASLR (Lee, 2011; Hu, 2012)



        1. Stork (Lee, 2012; Hungerford, 2007)



    1. Palpation



        1. Multifidi



        1. Pelvic Floor



        1. Muscle Sequence – hip extension



    1. Outcome measures

      1. Pelvic Girdle Questionnaire (Stuge, 2011; Grotle, 2012)

      2. Modified Oswestry Low Back Questionnaire

      3. Lower Extremity Functional Scale



  1. Treatment of SIJ Dysfunction

A. Treatment techniques/Muscle activation corrections

  1. Stork with cues



  1. ASLR



  1. SI Belt



  1. Pelvic Brace



  1. Case Studies



  1. Question/Answer


Resources

  1. DonTigny, R. Sacroiliac 201: dysfunction and management: a biomechanical solution. Jour of Prolotherapy 3:644-652.2011.

  2. Grotle M, Garratt A, Jenssen H, Stuge B. Reliability and construct validity of self-report questionnaires for patients with pelvic girdle pain. Physical Therapy. 92(1):111-123. 2012.

  3. Hu H, Meijer OG, Hodges PW, Bruijn SM, Strijers RL, Nanayakkara PWB, van Royen BJ, Wu W, Xia C, van Dieen JH. Understanding the active straight leg raise (ASLR): An electromyographic study in health subjects. Manual Therapy 17:531-537. 2012.

  4. Hungerford B, Gelleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 28(14):1593-1600. 2003.

  5. Hungerford B, Gilleard W, Moran M, Emmerson C. Evaluation of the ability of physical therapists to palpate intrapelvic motion with the stork test on the support side. Physical Therapy. 87(7):879-887. 2007.

  6. Lee D. The Pelvic Girdle, fourth edition. Churchill Livingston Elsevier. 2011

  7. Massery M. Impaired breathing mechanics and/or postural control. Cardiovascular and pulmonary Physical Therapy. Elsevier. 2012.

  8. Pardehshenas H, Maroufi N, Sanjari MA, Parnianpour M, Levin SM. Lumbopelvic muscle activation patterns in three stances under graded loading conditions: Proposing a tensegrity model for load transfer through the sacroiliac joints. J of Bodywork and Movement Therapies 18:633-642. 2014.

  9. Stuge B, Garratt A, Jenssen H, Grotle M. The pelvic girdle questionnaire: A condition-specific instrument for assessing activity limitations and symptoms in people with pelvic girdle pain. Physical Therapy. 91(7):1096-1108. 2011.

  10. Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. Journal of Anatomy 221:537-567. 2012.










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