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Sacroiliac
Joint Dysfunction
Vladimir
Djuric, M.D.
Although sacroiliac joint dysfunction (SIJD) may be present in as many as 40% of
individuals who experience back, buttock, and leg pain, it is frequently
overlooked as a cause of these common symptoms. Of those clinicians who are
familiar with SIJD, many feel it holds the distinction of being the single most
common cause of chronic or recurrent low
back pain. Despite its prevalence, SIJD
is vastly under-recognized and often misdiagnosed. Even those practitioners who
routinely treat it are frequently perplexed and frustrated by its complexity.
There are many different manners in which SIJD can manifest. In some cases the
symptoms creep in gradually without an obvious cause. It is common during the
second or third trimester of pregnancy and following lumbar fusion. Most
frequently, trauma to the SIJ leads to injury of the SIJ ligaments. In any case,
the resulting dysfunction disrupts the kinetic chain in which the SIJ is a key
link. Subsequently, restoring normal function can be extremely challenging and
in some cases virtually impossible.
Being a transitional structure, the SIJ can be thought of as either the bottom
of the spine or the top of the leg; it really functions as both. The joint is
not very large, especially considering the forces which cross it. What accounts
for its stability are its irregular joint surfaces, wedge-like shape of the
sacrum, and most importantly, the binding
ligaments – the SIJ ligament
complex. These ligaments, considered the strongest ligaments in the body,
function like the cables of a suspension bridge. In order for the joint to
function properly, each “cable” needs to provide a certain degree of tension
and support; each plays a role in bridging the spine to the lower extremities,
thus providing the stability necessary for fluid gait and normal body function.
When the ligaments are stretched or torn, as a result of either a single trauma
or repetitive impact loading, joint motion is altered. Joint dysfunction is the
end result.
Even though the most powerful muscles in the body surround the SIJ, these
muscles influence SI motion only indirectly. However, the effect the SIJ has on
these muscles can be profound. The piriformis, iliopsoas, gluteals, quadratus
lumborum, and hamstrings can all be affected to various degrees. With SIJD these
muscles can become tense or spastic, ceasing to perform effectively. This
further compromises gait and can lead to development of spinal dysfunction, hip
bursitis and leg pain.
SYMPTOMS
With SIJD most common complaint is pain in the buttock, hip, and/or low back.
However,
groin pain, more distant leg pain, burning, numbness, and tingling can
also be experienced. In fact, SIJD is frequently mistaken for sciatica thought
to be of lumbar origin. So convinced is the treating physician that there is a
herniated disc responsible for the leg symptoms that 2 or 3 lumbar
MRIs may be
obtained, searching for that elusive disc herniation.
As with the spraining of any joint, be it an ankle or SI, a sense of joint
looseness or instability may be present. Excess motion in the form of abnormal
shearing or rotation of either the sacrum or ilium can lead to joint subluxation
and locking. The patient’s interpretation of such an event is most commonly
“my hip/back/SI is out.” In addition to a sense that something is out of
place, symptoms including increased pain, compromised movement, and an overall
intolerance of certain positions, postures and activities may be present. SIJD
can also be responsible for bowel and bladder irritability, sexual dysfunction,
and a host of other symptoms.
TREATMENT
In order to successfully treat SIJD, several factors need to be taken into
consideration and properly addressed. These include altered joint mechanics,
muscle dysfunction, and ligament incompetence. Manual therapy serves to
re-educate the body. Various
manipulation
and mobilizations, some of which
utilize the principle of indirect muscle effect on SIJ motion (muscle energy)
help to realign the
pelvis
and spine. When possible, self-mobilization
techniques are taught, enabling the patient to restore alignment on their own or
with the help of a partner. Instruction in body mechanics and activity avoidance
helps prevent recurrent subluxations.
It is important to restore proper muscle length, tone, strength and
coordination. In order to address this
myofascial
component, the patient is
instructed in specific exercises, including a regimented stretching program --
an essential piece of the puzzle. Tight or spastic muscles inhibit progress and
are many times responsible for perpetuating the dysfunction. Aquatherapy is
useful means of initiating motion recovery and restoring movement patterns,
particularly when excessive deconditioning or pain is an issue.
In cases where a leg length discrepancy (LLD) exists, heel lifts are utilized to
reduce the degree of imbalance. In some cases, the leg length may be the cause
of the dysfunction. More frequently, a previously asymptomatic leg length
difference contributes to instability. Whereas prior to the injury, the
ligaments were strong enough to compensate for the imbalance, after the injury
this is no longer the case.
There are two types of LLD: true and functional. True LLD means that the bones
of one leg from the heel to the hip joint are actually shorter than the other.
With functional LLD, anatomic leg length is relatively equal. However, because
of abnormal alignment in either the pelvis or lumbar spine, one side appears as
if it were shorter than the other. The only accurate way to discriminate between
the two is by obtaining a standing
x-ray
of the pelvis, then actually measuring
hip heights on the x-ray film. A heel lift is sometimes necessary to correct for
an excessive difference.
External supports in the form of a sacroiliac belt or possibly a firm girdle
provide a degree of external stability during recovery. Some patients claim that
even wearing a tight-fitting pair of jeans makes them more comfortable. These
measures can be helpful in assisting the healing process, but are many times
inadequate.
Prolotherapy
addresses the underlying cause of chronic SIJD:
Ligament incompetence and joint hypermobility. Proliferant injections help in
achieving the desired goal of strengthening and perhaps shortening the
ligaments, thus decreasing the hypermobility and in turn improving overall joint
dynamics.
The comprehensive approach described seems to have a synergistic effect on
recovery. Such multifaceted care is especially necessary to treat the more
complicated and chronic presentations of SIJD. With such cases, nutritional and
hormonal effects on healing must not be overlooked. In circumstances where all
other components of treatment have been addressed and properly executed, success
may not be achieved specifically because an individual’s capacity to heal is
compromised. For this reason, smoking cessation, nutritional support, and
treatment of hormonal imbalances is essential.
My personal experience with SIJD has been both rewarding and frustrating. I have
encountered situations where a seemingly simple and straightforward case turned
out to be extremely complicated and challenging, necessitating a year or more of
intensive treatment. Other times, what on the surface appeared to be quite
complex was resolved with only minimal intervention. Admittedly, this is more
the exception rather than the rule. But the lesson to be learned is that
regardless of the chronicity, complexity and number of setbacks, improvement may
be just around the corner. Our motto: never give up.
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