dysfunction of sij

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0000-0000/79/0001~0023$02.00/0THEJOURNALF ORTHOPAEDICND SPORTSHYSICALHERAPYCopyright O The Orthopaedic and Sports Medicine Sections of the American PhysicalTherapy Associaton

Dysfunction of the Sacroiliac Joint andIts Treatment*RICHARD L. DONTIGNY,S, PT t

A very common but frequently overlooked cause of pain in the low back is a resultof leaning forward without adequately supporting the anterior pelvis. This allowsthe innominates to rotate slightly downwards on the sacrum with fixation and anapparent increase in the length of the legs, which in turn irritates the sciatic nerve.This commonly occurs bilaterally but may occur on just one side. Flexion of theinnominate(s) on the sacrum restores function to the sacroiliac joint, causes anapparent shortening of the legs and gives excellent relief of pain in the low backand sciatic pain.

Pain in the low back has been diagnosed andmisdiagnosed, treated and mistreated for dec-ades. The purpose of this article is to take afresh look at pain in the low back, to describethe forces that precipitate the pain, to demon-strate a very simple method of relieving the painand preventing recurrence, and to detail theconservative management of the problem.

"In a Columbia-NYU study of 5,000 unse-lected back pain cases, muscle weakness orinelasticity was found to be the cause of pain in81 percent. All other causes-including her-niated intervertebral disk, tumor, arthritis, frac-ture, bone abnormality-made up only 19 per-cent."I6 It will not be within the scope of thisarticle to discuss the management of disks, tu-mors, arthritis, or fractures, but rather the treat-ment of the other 81%, where physical therapistscan be most effective.MECHANISM

During normal standing posture the line ofgravity passes slightly posterior to the center ofthe a~et abul a.~~ .3 When the preponderance ofthe weight of the upper trunk is carried on theposterior pelvis, the pelvis rotates downwardposteriorly, around the acetabula, creating a ro-tational force in flexion (Fig. 1). A pelvic tilt iscreated automatically, with litt le or no assistance* From the Northern Montana Hospital. P. 0. Box 1231.Havre, MT59501.t Chief PhysicalTherapist.

from the abdominal muscles. Contrary to somemyths, man was beautifully designed to standerect.

Dysfunction occurs, not just during lifting, butwhen the patient leans forward or stands withlordotic posture. This causes the line of gravityto be displaced anterior to the center of theacetabula7.l5 reating a rotational force in exten-sion around the acetabula (Fig. 2). If anteriorpelvic support from the abdominal muscles isadequate, there is no problem. If, however, sup-port from the abdominal muscles is not ade-quate, the anterior pelvis rotates downwardsaround the acetabulae. This anterior rotationalforce tends to rotate the innominate bones an-teriorly on the sacrum, but because the sacrumis placed within the innominates and is wideranteriorly than posteriorly, the innominate bonestend to spread on the sacrum. On reaching thelimit of their motion, they wedge and lock.

By superimposing Figure 1 over Figure 2 (Fig.3) we can see how the relationship of the ace-tabulum to the sacroiliac joint is changed. As theacetabulae move downwards and slightly pos-teriorly it causes an apparent lengthening of thelegs. More common bilaterally, it frequently oc-curs unilaterally, causing pelvic obliquity and ahigh iliac crest on the same side when the patientis standing." L a r ~ o n ~ ~xpressed the belief thatthe presence of a lumbar convexity on the sideof the long leg depends on a sacroiliac lesionbeing present on that side.

The apparent leg length difference, and thus


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DONT IGNY Vol. 1, No. 1

Fig. 1 Sacroiliac region in normal posture. Arrows indicatenormal rotation force in flexion. (Courtesy of The D.O.)

Fig. 2. Region in lordotic posture. Reversal of rotation forcearound the acetabula with anterior shift of the line of gravitycan be seen. (Courtesy of The D.O.)

the amount of excursion of the acetabulum, onthe involved side can be measured from theposterior superior spine of the ilium to the medialmalleolus and compared before and after cor-rection or compared with the same measurementon the uninvolved side. Differences are usuallyfrom 3/8-5/8 in (1 -1.5 cm). Measurements fromthe anterior superior spine to the medial malleo-lus are not relevant in themselves because theexcursion of the anterior superior spine is ap-

proximately the same as or more than that of theacetabulum.

Several authors have described anterior dys-function of the sacroiliac joint, but some havereferred to it in different terms such as "forwardtorsion sprain" or "sacroiliac slip".8, 18 . 24. 26-28EVALUATION AND CORRECTION

The passive straight leg raising test is mosthelpful in the evaluation of pain in the low back.Pain down the leg on passive straight leg raising,which is exacerbated by dorsiflexion of the foot,is indicative of sciatic nerve pain. Despite a studyto the contrary by Danforth and W i l ~ o n , ' ~everalresearchers have found a relationship betweensciatic nerve pain and pain in the sacroiliacjoint.l 8. 38. 40

When the leg is raised, the pull of the ham-strings on the innominate bone causes a poste-rior torsion strain on the same side.27 f this doesnot increase the pain in the back or if it easesthe pain in the back, anterior dysfunction shouldbe suspected. If passive straight leg raisingcauses pain or increases the pain on the sameside, suspect a posterior or vertical complication.If passive straight leg raising causes pain on thecontralateral side, suspect anterior dysfunctionon the opposite side (rotating one innominate

Fig. 3. Overlays of pelvis. Dotted line indicates position ofthe pelvis in lordotic posture and solid line that in normalposture. Movement of the acetabula can be seen. (Courtesyof The D. 0 . )


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Summer 1979 DYSFUNCTION OF SACROILIAC JOINT 25posteriorly, increases anterior dysfunction onthe opposite sidez7).

The most consistent sign that confirms thesuspicion of anterior dysfunction is the mannerin which the leg seems to shorten when theinnominate is flexed on the sacrum. "If anteriordysfunction of the sacroiliac joint is suspected,an evaluation should be made to see if there isan apparent lengthening of the leg. The patientis placed supine on an examination table and hiships and knees are flexed toward his chest toflatten the lumbar spine, to minimize pelvic obli-quity, to make sure the buttocks lie evenly anddo not distort the patient, and to aid the patientto l ie in a straight line. Then the hips and kneesare extended to the table in the midline. Theexaminer stands at the foot of the table andgrasps the patient's heels, one in each hand.The patient's hips are slightly flexed with theknees extended, and his heels are abductedfrom 12-1 6 in (30-40 cm). An upward thrust ismade as if to thrust the heads of the femurs intothe hip sockets. After this they are adducted andlowered to the table with an equal amount of mildmanual traction on each, the medial malleolibeing held together in the midline and care beingtaken to ensure that the patient is lying straight.This is similar to a method described by Beal,4but the addition of some mild traction after theupward thrust seems to increase the apparentdifference in leg length. If the leg on the painfulside appears to be from 3/8-5/8 in (1-1.5 cm)longer at the malleoli or at the heels than thenormal one, it may indicate anterior dysfunctionof the sacroiliac joint with apparent leg lengthen-ing on that side."" When evaluating the com-parative leg length at the malleoli, any differencewill be more obvious if you place a thumb be-neath each medial malleolus when holding themtogether.

"In the case of a suspected apparentlengthening of the right leg, confirmation is madeby mobilization in the following manner: with thepatient supine on the examining table, the ther-apist stands at the patient's r ight side and placeshis right hand between the patient's legs underthe right ischial tuberosity and buttock. Then heplaces the heel of his left hand on the anterior-superior spine of the ilium with the fingers point-ing laterally and rotates the right innominatebone strongly back and upward. Then he reex-amines the patient's legs to see if the malleoliare even.""

An alternative method may also be used. Thetherapist stands facing the r ight side of the tableand passively flexes the patient's right hip andknee along side of the chest toward the patient'saxilla (Fig. 4), stretching slowly and firmly withthe left elbow on the patient's right knee andgrasping the patient's right ankle with the lefthand. With the right hand, the therapist mayeither hold down the opposite leg, or grasp thepatient's right ischial tuberosity and pull it up-ward, reinforcing the posterior rotational forcewhile a colleague holds the left leg down on theexamining table (Fig. 5). Then slowly lower theleg to the table and recheck at the malleoli tosee if they are even and if the apparent leglengthening is corrected. In addition, the patientmay be instructed in correcting this himself aspart of his postural exercise program. This canbe done when supine, standing, or sitting asshown in Figure 6.

If the legs appear to be even at the malleolibut bilateral anterior dysfunction of the sacroiliacjoint is suspected, an attempt should be made to

Fig. 4. Method of mobilization to cor rect anterior dysfunctionof the sacroiliac joint and reduce apparent lengthening of theleg. (Courtesy of The D.O.)

Fig. 5 . Alternate method of treatment, viewed from above.(Courtesy of The D.O.)


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26 DONTIGNY Vol. 1 , No. 1

Fig. 6. Methods of self-correction. A, correction standing orsupine, pull the knee into the ipsilateral axilla. Alternateseveral times. 6, ith one foot on a table or bench, leantoward the knee stretching it into the axilla. Alternate. C,when sitting, pull one knee into the axilla and sit w ith it therefor a few minutes. Alternate. Repeat these many times duringthe day and always make a correction just before bed thatwill relieve the strain on the involved ligaments for severalhours.

rotate each innominate bone posteriorly on thesacrum. One innominate bone is rotated poste-riorly, and then the patient is reexamined to seeif the corresponding malleolus now appears tobe higher than the uncorrected one, indicatingcorrection into a shortened position. He then tipsthe uncorrected side posteriorly, and if a correc-tion has been made, the malleoli will appear tobe even. Frequently one side will be much moredifficult to correct than the other, and for thisreason an attempt at correction should be madeon each side. When the less involved side iscorrected, the difficulty in correcting the otherside is lessened. Correction not only confirmsthe supposition of anterior dysfunction of thesacroiliac joint, but has the advantage of reliev-ing the pain in the lower part of the back whenapparent leg lengthening is present. One or twosessions of treatment may be enough to correctthe condition if it results from recent trauma; butif the patient has suffered from recurrent back-ache and displays an obvious weakness of theanterior pelvic support, the malleoli must bechecked at each treatment session and the ap-parent lengthening corrected as necessary torelieve the strain on the involved ligaments andallow them to recover." It is frequently neces-sary to flex each innominate on the sacrum al-ternately, two or three times, until no more ap-parent shortening takes place.

A Complication of Anterior DysfunctionIf a patient has pain in the low back on the

ipsilateral side during passive straight leg rais-ing, when a posterior torsion strain is placed onthe sacroiliac joint, i t is not necessarily indicativeof a posterior sprain or posterior dysfunction ashas been proposed.27.8 If ipsilateral pain is in-creased with flexion of the innominate on thesacrum, with the patient supine, grasp the legabove the ankle and put traction on the leg inthe long axis. Pull firmly and then recheck themalleoli. The involved leg will now appear to beequal to or longer than the uninvolved leg. Nowwhen the innominate is flexed on the sacrumthere should be no pain and the leg will appearto shorten with correction. The direction of themaneuvers that relieve the pain and the resultantchanges in apparent leg length give us importantclues as to the nature of the dysfunction. Appar-ently the innominate rotates slightly anteriorly onthe sacrum and then, perhaps after prolongedsitting, slips cephaladly complicating the originaldysfunction. This, then, requires two separatemaneuvers to correct-traction on the leg tocorrect the vertical slip and then flexion to cor-rect the anterior dysfunction. Posterior torsionsprain or posterior dysfunction may exist by it-self, but it is not common.

MEASUREMENTSMeasuring the leg length in the conventional

manner from beneath the anterior-superior spineof the ilium to below the medial malleolus prob-ably will not demonstrate any appreciable differ-ence between the side with the apparentlengthening and the normal side. Menne1Iz7sug-gested that while the patient is standing bothlegs be measured from the anterior-superior liacspines to the floor and from the posterior-supe-rior iliac spines to the floor. This will make ap-parent any rotation of the pelvis on one side orthe other. The apparent increase in leg lengththat occurs with the anterior dysfunction of thesacroiliac joint may make the crest of the iliumon the involved side higher than the crest on theuninvolved side even though the anterior-supe-rior spine of the ilium on the involved side maybe even with or slightly lower than the other.When this occurs, the posterior-superior spinewill measure slightly higher on the involvedside.''


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Summer 1979 DYSFUNCTION OF SACROILIAC JOINTIf each measurement on one side is longer

than each measurement on the other side, anactual difference in leg length is probable. In thepresence of even moderate pain in the lower partof the back, it is not possible to determine adifference in actual leg length without first mo-bilizing the innominate bone upward and poste-riorly to see if apparent leg lengthening is pres-ent. Bailey and Beckwith3 stated that "often adifference of a centimeter or more in the heightsof crests will be wiped out following the correc-tion of a pelvic lesion." The posterior-superiorspines also will measure lower after mobilizationtreatment than before. With the patient prone,careful measurements from the posterior-supe-rior spines to the medial malleoli before and aftermobilization will demonstrate shortening of from

in (1 -1 .5 m)."In order to determine whether the high crest iscaused by a difference in leg length causing a

pelvic obliquity or by pelvic obliquity causing anapparent difference in leg length, the level of theiliac crests should be checked first with thepatient standing and then with the patient sittingon a firm surface. If one crest is still high withthe patient sitting, then i t is probable that pelvicobliquity caused the apparent discrepancy in leglength. Crest height during sitting frequently isequalized after proper corrective manipulation."DEMONSTRATIONS

Roentgenograms were taken before and aftermobilization of an apparent leg lengthening ofthe left lower extremity of a 21-year-old man.The patient was positigned supine on the roent-gen ray table and both knees were flexed to hischest to flatten the lumbar spine, minimize pelvicobliquity, and assure the symmetry of the glutealmuscles. The patient's feet were then extendedto a tape mark on the table while the hips andknees were left comfortably flexed, and a roent-genogram was made. Then the left innominatebone was moved posteriorly on the sacrum anda second roentgenogram was taken with thepatient in the same position. Tracings of theroentgenograms (Fig. 7) demonstrate the move-ment that took place. The pelvis was flattened.The sacral plateau was flattened, indicating flat-tening of the lumbosacral angle. Slight reductionof the width of the pelvis suggests that the in-nominate bones may have been wedged apartby the sacrum prior to mobilization. The acetab-

Fig. 7 . Tracings of roentgenograms. Doffed line representspelvis before correction of anterior dysfunction of the sacro-iliac joint on the left. Solid line shows pelvis after correction.Tracings were overlaid to demonstrate movement that oc-curred on correction. (Courtesy of The D.O.)

ulum on the left was higher than the one on theright without a corresponding increase in heightof the iliac crest. This suggests rotary movementrather than a lateral tilt. The right deviation of thepubic symphysis moved medially with some lat-eral movement of the right ilium on the sacrum.Finally, there was a definite movement down-ward of the left ilium on the sacrum, seen at theposterior-superior spine and greater sciaticnotch in relation to the first sacral foramen.I8

Roentgenograms were made of a secondyoung man with a suspected bilateral anteriordysfunction of the sacroiliac joints, before andafter flexing each innominate on the sacrum.These were done with the patient standing,weight evenly distributed on both feet and theknees fully extended. A roentgenogram (Fig. 8)was made before correction, a second (Fig. 9)after flexion of the right innominate on the sac-rum, and a third (Fig. 10) after flexion of the leftinnominate on the sacrum. Figure 9 shows aslight flattening of the sacral plateau. Figure 10shows a definite flattening of the sacral plateauwith a resultant, widening of the L5-S1 inter-space. It also shows a definite movement down-ward of the posterior superior spines in relation-ship to the first sacral foramina.ASSOCIATED CONDITIONSReferred Pain

Pain most commonly found with anterior dys-function is "tenderness over the symphysis


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Fig. 8. Roentgenogram of a suspected bilateral anterior dysfunction before correction.

pubis on the side affected, tenderness over theiliosacral articulation on the side affected, andtenderness along the crest of the ilium where theabdominal muscles are attached.26 Norman andMay32 ound that "a sacroiliac lesion producespain over the gluteal region, the posterior thigh,the posterolateral calf and the lateral border ofthe foot."

Occasionally there will be associated pain inthe abdomen at Baer's sacroiliac point, whichhas been described as being 2 inches from theumbilicus on a line drawn from the umbilicus to.the anterior-superior spine.27 Torsion strain onthe sacroiliac joint can modify tenderness at thispoint. Norman33 also found abdominal pain as-sociated with sacroiliac dysfunction. Wilson42called attention to the fact that "unusual radia-tion of pain from the lower three lumbar vertebraljoints has led to the unnecessary removal ofpelvic organs in the female and to coccygec-tomy."

Although sciatic nerve pain is frequently as-sociated with anterior dysfunction of the sacro-iliac joint it is probably not a referred pain. Dan-forth and Wilsoni4 determined that the sacroiliacjoint did not act directly to cause sciatic nervepain because "there is no canal nor semblanceof a canal which holds the nerves against thejoint." It seems reasonable that the nerve trunkcould be irritated directly by the undue stretchingof the sciatic nerve associated with the apparentlengthening of the leg found with anterior jointdys fun~t ion . '~n a person with an anterior dys-function the nerve is stretched even more withevery step during normal gait; when flexion ofthe hip i s followed by extension of the knee anddorsiflexion of the ankle, which is merely a ver-tical variation of Lasegue's test. Cailliet6 explainsthat "stretching the nerve stretches the duralsheath of the nerve and thereby impairs its bloodsupply, the ischemia of the nerve causing thepain."


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Summer 1979 DYSFUNCTION OF SACROILIAC JOINT 29Pain on Sitting

If wedging at the sacroiliac joints has alreadyslightly spread the innominate bones, any pres-sure that might increase the spreading and theresultant ligamentous stretch probably would bep a i n f ~ l . ' ~rant2' stated that "In the standingposture, the acetabula and the sidewalls of thepelvis tend to be forced together, but the pubicbones, acting as struts, prevent this from hap-pening. In the sitting posture the ischial tuber-osities tend to be forced apart."

Note in Figure 3 that when the innominatesare rotated, the ischial tuberosities are behindtheir normal position. Weight-bearing on themduring sitting increases the anterior rotationalstrain on the ligaments, tending to spread theinnominates and increasing the distance be-tween the posterior superior spines. Menne1I2'found an approximation of the posterior superiorspines on sitting from prone, while Colachisi0

found a separation. Actually, they can go eitherway, depending on whether the patient is sittingwith the pelvis slightly extended with anteriorjoint torsion or with the pelvis slightly flexed withposterior joint torsion.

There is little or no pain on sitting if the patientwill sit 4 or 5 in (10-1 2 cm) from the back of thechair and then slump, sitting on the back of thepelvis rather than on the bottom of the pelvis.Nachemson's studies3' have found an increasein intradiscal pressure on sitting but the authorbelieves that it is probably not related to painproduced by the sacroiliac joint on sitting, be-cause while sitting in some degree of extensionmay be painful, sitting in flexion is usually not,especially after proper mobilization.Pain on Increase of lntraabdominal Pressure

Anything such as coughing or sneezing orconstipation which increases intraabdominal

Fig. 9. Bilateral anterior dysfunction after flexion of the right innominate on the sacrum.


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Fig. 10. Bilateral anterior dysfunction after flexion of the left innominate on the sacrum. Note widening of L5-S1 interspace andmovement downward of the posterior superior spines in relationship to the first sacral foramina.

pressure has a tendency to spread the innomi-nates and may precipitate pain or increase ex-isting pain.

The increase in intradiscal pressure that ac-companies an increase in intraabdominal pres-sure may not be associated with the increase inpain because if you stabilize the pelvis by man-ually compressing the ilia you can usually sneezeor cough in relative comfort and this maneuveris not likely to affect intradiscal pressure oneway or another.Changes in Gait

Charles Ducroquet was reported by his sonsto have remarked that certain painful reactionsof the sacroiliac joints lead to a shortening of thestep. His sons added this comment: "The painof torsion of the sacrum on the iliac wing, inreality, limits the pelvis ~ t e p . " ' ~he length of the

step may also be shortened to protect a painfulsciatic nerve.

Climbing stairs is frequently painful. Weaknessin the anterior pelvic support allows the innomi-nate to rotate downward on the sacrum as thehip flexors, pulling from the iliac fossa, raise theweight of the leg upward during swing phase.

Chronic weakness in the anterior pelvic sup-port, especially accompanying obesity makesthe hip flexors less efficient by approximatingthe origin to the insertion. The patients will fre-quently walk with their hips in external rotationusing their hip adductors to assist with flexion.This can cause a valgus deformity at the knees.Pain During Pregnancy

Anterior dysfunction is particularly commonduring pregnancy as weight on the anterior pel-vis causes an anterior torsion strain on the sa-


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Summer 19 79 DYSFUNCTION OF SACROILIAC JOINT 31croiliac joints. Relief can be obtained by frequentflexion of the knee to the axilla and by instructingthe patient to lean slightly backwards from thehips when standing so that most of the trunkweight is on the posterior pelvis.Instability Before the Menstrual Cycle

Women are particularly susceptible to anteriordysfunction about a week or 10 days before themenstrual cycle. The presence of relaxin in thebody at that time precipitates a hormonal liga-mentous laxity that renders the pelvic ligamentsmore prone to minor injury. The relaxin is reab-sorbed during the menstrual cycle and, if theinnominate is kept in its normal position on thesacrum at this time, the pelvic ligaments regaintheir normal stability. It has been our observationthat if the dysfunction is not corrected, the insta-bility may continue until the next menstrual cycle.MANAGEMENT

Evaluation and mobilization must be done be-fore the application of any modalities. It is essen-tial that the patient and the therapist be acutelyaware of any movement which initiates or elim-inates, aggravates or alleviates pain. You do notmobilize into pain. Everything must be donewithin the limits of pain.

Rest in BedDuring the acute phase, rest in bed is very

important. When lying on the side, place a pillowbetween the knees. When lying supine, a pillowplaced under the low edge of the buttocks isextremely helpful. This tends to keep a slightpressure in posterior rotation and frequently re-lieves all pain so that the patient can rest muchbetter. Making the patient comfortable frequentlymakes additional medication unnecessary.Modalities

For the relief of chronic pain, we find thatmobilization followed by heat, electric stimulation(with or without ultrasound), and massage iseffective. The currents used for transcutaneouselectrical nerve stimulation5. 5. 35. 37 are particu-larly helpful in relieving back pain and their ef-fects seem to last much longer if used aftermobilization correction. If the pain is acute, wefollow mobilization with electric stimulation, mas-sage, and an ice pack. Heat, while analgesic, is

not anesthetic. Cold, while anesthetic, is notparticularly analgesic. Whether you use wet ordry heat is unimportant. While wet heat is morepenetrating than dry heat at the same tempera-ture, dry heat can be tolerated at higher temper-atures. At the hiqhest tolerated temperatures,heat penetration is about equal.' When cold isused, there is little point in applying it before theelectric stimulation and massage as this willwarm the area which has been cooled. The ef-fects of the cold will last longer when appliedafter the other modalities. The cold should beapplied over a dry towel or a warm damp towelto avoid an initial shock to the patient. Relaxationis enhanced if heat is applied to another part ofthe body while the cold packs are in place tomaintain core tem pe rat ~re .~.7 3 31

The use of continuous heat prior to mobiliza-tion is contraindicated. The local increase incirculation from the prolonged application ofheat causes edema which frequently preventsmobilization correction.Traction

Pelvic traction does not seem to be helpful inthe treatment of anterior dysfunction of the sa-croiliac joint. However, wrapping the pelvic trac-tion belt snugly around the pelvis does seem tohelp prevent recurrence by preventing the in-nominate bones from spreading and thus limitingthe amount of wedging possible. The overlap-ping flaps from a Scultetus binder with a tailstitched to it posteriorly make an excellent pelvictraction belt, which is comfortable and com-pletely adjustable."

Leg traction applied to a patient with apparentlengthening of the leg serves only to increasethe deformity, pulling on the longer involved sidewhen shortening is necessary."

Intermittent traction is effective in separatingthe vertebrae which may be necessary to relievepressure on a disc.g In the presence of pain froma facet syndrome intermittent traction may sep-arate the vertebrae enough to relieve the bindingand allow normal realignment.

ExerciseProper exercise is absolutely essential to re-

lieve pain and to prevent recurrence of jointdysfunction. The patient must be instructed thor-oughly in what to do, how to do it, and why itmust be done. The 1st day, demonstrate to the


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32 DONTIGNY Vol. 1 , No. 7patient what must be done. The 2nd day, havethe patient demonstrate what is being done socorrections may be made if necessary.

Correction of anterior dysfunction by flexionof the innominate on the sacrum is done byhaving the patient flex his knee to the axilla asshown in Figure 6. This must be done two orthree times on each side, alternating sides. Thisshould be done several times a day and espe-cially upon going to bed to relieve the dysfunc-tion and allow the ligaments several hours duringthe night to recover. This minimizes getting upwith a stiff sore back in the morning. Flexion ofthe knee to the chest flexes the pelvis and thespine and does not provide adequate correction.Flexion of the knee to the axilla flexes the innom-inate on the spine.

In order to prevent recurrence of back pain,the patient must learn to use his abdominal mus-cles constantly to support the anterior pelvis. Itis especially important to hold the abdominalmuscles in tightly and to pinch the buttockstightly together to stabilize the pelvis when lean-ing forward, whether to shave, make a bed, workover a counter, or to lift something.

The abdominal muscles should bestrengthened to provide sufficient pelvic supportby doing a partial sit-up, with the hips and kneesbent. Leg-raising exercises should never beused as an abdominal strengthening exercise.Aside from the fact that the abdominal musclesdon't raise the legs, in the absence of a strongstabilizing force from the abdominals on the an-terior pelvis, the pull of the iliacus from the iliacfossa causes a strong anterior rotational force ofthe innominate bones on the sacrum. All legraising exercises should be ~ontr ain dic ated .~

The downward inclination of the pelvis andincreased difficulty in doing a pelvic tilt whichoccurs with anterior joint dysfunction gives theimpression of tightness in the hip flexors. Eval-uation of hip flexor tightness should be madefollowing correction. lfstretching of the hip flex-ors are necessary, it should be done with careas it puts an anterior rotation strain on the sacro-iliac joint, which may precipitate or increase ananterior dysfunction of the sacroiliac joint.Supports

Occasionally it may be necessary to use asupport, especially with long-standing obesity,excessive abdominal weakness, or chronic jointinstability. Its use should supplement but notreplace a good prophylactic postural training

program. It should be put on after treatmentwhen the joint dysfunction has been corrected.A good sacroiliac support or even a simple trou-ser belt worn just below the anterior-superioriliac spines will serve to stabilize the pelvis, al-though a good lumbosacral support of fabric withat least two paravertebral metal stays and ad-justable side lacing will be more effective. Thisprovides stability in both pelvic and lumbar flex-ion. To be most effective, the support must beput on properly. The patient should lie supine onthe opened support and flex his knees to hisaxillae as described. This also minimizes thesacral angle, flattens the lumbar lordosis, andlessens pelvic obliquity. He then places his feetflat on the table, with the hips and knees flexed,and the support is fastened and adjusted snugly,especially around the pelvis, where it tends torelieve the strain on the pelvic ligaments bypreventing spreading and locking. In this positionthe support will help to maintain the posturalcorrections that have been made and to preventrecurrence of the anterior dysfunction. If thesupport is put on when dysfunction is not cor-rected, it not only will fail to correct the jointdysfunction, but may increase pain by increasingpressures on the pelvic joints in that position."Heel Lifts

A heel lift may be prescribed for a patient withone leg shorter than the other, but only aftercareful measurements indicate an actual bonydiscrepancy. A heel lift should not be consideredif apparent differences in leg length can be cor-rected quickly by a painless mobilization maneu-ver.

Heel lift therapy is frequently used to correcta high iliac crest in patients with idiopathic sco-liosis. These patients should also be evaluatedfor anterior dysfunction of the sacroiliac jointbefore recommending a heel lift.Transcutaneous Nerve Stimulators

While electric stimulation is extremely helpfulin the acute phase, after the patient has beenestablished on an effective home program, it isseldom necessary. It is occasionally helpful incases of obesity and chronic joint instability.FUNCTION

The sacroiliacjoint is a strong joint structurallyand in recent years it has been regarded as a"misconception" that "the sacroiliac joint was


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Summer 1979 DYSFUNCTION OF SACROILIAC JOINT 33susceptible to strain and subluxation from trivial

Gray's Anatomy2' states that the function ofthe sacroiliac joints is to lessen concussion inrapid changes of distribution of body weight ineach of two directions. In doing so it undergoessome rotation through a transverse axis. Onecomponent of the force is expended in drivingthe sacrum downward and backward and is re-sisted by the wedge shape of the sacrum andthe sacroiliac and iliolumbar ligaments. The sec-ond component of force produces a rotatorymovement by which the superior end of thesacral articulation is tilted down and the inferiorpart up and is resisted by the wedge form andthe sacroiliac, sacrotuberous, and sacrospinousligaments. The joint acts as a shock absorber. Ifan outside force creates a minor displacementof the articular surfaces of the sacroiliac joint,the displacement is quickly corrected by thestrong pull of the surrounding ligaments aidedby the wedge shape of the sacrum.

O ' D ~ n o g h u e ~ ~tated that the sacrum is thekeystone of the pelvic arch. Grant2' describedthe rotary movement of the sacrum and stated:"The articular surfaces of the sacrum are fartherapart in front than behind: so, the sacrum be-haves not as a keystone, but as the reverse of akeystone, and tends therefore to sink forwardsinto the pelvis. As it does so, the posterior liga-ments become taut and draw the ilia closer to-gether with the result that the interlocking ridgeand furrow engage more closely. Here is anautomatic locking device."

This would seem to bear out the early obser-vations of Cunningham,12 of which Dwight saidthat "As the sacrum narrows towards its dorsalsurface, and is really suspended from the iliacbones by the posterior sacroiliac ligaments, itcannot be considered as the keystone of anarch." In its normal functioning state, the sacro-iliac joint is a nonweight bearing joint.

S ~ h u n k e ~ ~oted that supernumerary sacroil-iac facets are common and stated that "onlyslight motion would be required to dislocate themor other slight irregularities upon the articularsurfaces. Tension of the interosseous ligamentswould tend to keep such prominences dislocatedand resist the separation necessary for theirrelocation, though they might be made to 'snap'back into position by more or less strenuousmobilization."

Trotter4' found that accessory sacroiliac artic-ulations occur in man in varying percentages.

"It would seem that the sacrum is well pro-

tected from sinking into the pelvis and the iliafrom rotating posteriorly on the sacrum. Unfor-tunately, the relatively thin sheath of anteriorsacroiliac ligaments does not offer the sameprotection from movement and injury in the op-posite direction. Anterior rotation of the innomi-nate bones on the sacrum not only tends toloosen the fibers of the strong posterior sacroil-iac ligaments, but spreads the ilia on the sacrumcausing them to wedge or bind. Fixation of thesacroiliac joint prevents function, and forces pre-viously expended in the joint are transmitted tothe intervertebral disk. This may be a significantfactor in herniation of the disk."l8

On heel strike, the force created travels up theleg and is absorbed in the sacroiliac joint as theinnominate is caused to rotate slightly posteriorlyon the sacrum, stretching the heavy posteriorsacroiliac ligaments which in turn cause the in-nominate to return to its normal resting position.If the function of the sacroiliac joint is blocked,then this posterior force, instead of being ab-sorbed, causes the entire pelvic ring to betorqued around the L5-S1 disk. It seems highlyprobable that this is the cause of the torsionchanges that occur in the disk before herniation.

Pain in the low back is also a frequent accom-panying affliction of patients with hip disease.The lateral thigh muscles that originate from theiliac crest posterior to the line of gravity and lieposterior to the greater trochanter are in a rela-tively shortened position during normal standingposture. In the lordotic posture and during an-terior dysfunction of the sacroiliac joint the in-nominate rotates around the acetabula so thatthe origin of those muscles on the iliac crestmoves anteriorly and the greater trochantermoves posteriorly and the muscles which laidposterior to the trochanter now lie over the topof the trochanter stretching those involved mus-cles. As those muscles are stretched and func-tioning from an unnatural position they also serveto pull the head of the femur more tightly into theacetabulum disposing it to increased wear fromthe increased pressure. This is probably exac-erbated by an increase in apparent leg lengthand increased trauma to the head of the femurbecause of the jarring effect created on heelstrike with the nonfunctioning sacroiliac joint.Individual anatomical variations and variations ingait are also contributing factors.COMMENTS

Before the work of Danforth and Wilson14 in1925, sacroiliac dysfunction was frequently


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34 DONTIGNY Vol. 1 , No. 1found and associated with sciatic pain, but sinceno anatomical relationship was found, the diag-nosis was assumed incorrect. When Mixter andBarr2' described the herniated intervertebraldisk in 1934 it was then assumed that sciaticpain was a result of a herniated disk. Since about60-70% of people with pain in the low backhave some degree of sciatic nerve irritation, butonly about 5% of patients with pain in the lowback undergo surgery for herniated disk, thisrelationship is unlikely. The relationship betweensacroiliac dysfunction and sciatic pain exists, butis biomechanical in nature rather than strictlyanatomical.

Of all cases with pain in the low back, referredto this department, just over 80% have anteriordysfunction of the sacroiliac joint and of those,about 55% were affected bilaterally.

Frequently radiographic evidence does notcorrespond to clinical evidence. Cyriax13 com-mented: "Everytime a patient is labelled 'cervicalspondylosis,' 'lumbar arthritis' or 'degeneratedisc' it is highly probable that an error in empha-sis has been made. Although this is what theroentgenogram shows, a few months from nowwhen the patient has no symptoms he will stillhave his osteophytes or his narrowed space."

Unfortunately, the traditional approach to mo-bilization of the sacroiliac joint has been an at-tempt to correct a high iliac crest by extendingthe innominate on the sacrum. This is usuallydone with the patient side-lying and with theoperator behind the patient pulling backward onthe shoulder and thrusting the innominate for-ward and downward on the sacrum. This is donein the mistaken belief that a high crest is causedby an upward dysfunction of the joint when,actually, the high crest is caused by anteriordysfunction and concurrent apparent lengthen-ing of the leg. This maneuver could serve toopen the joint slightly at which time the tautsacroiliac ligaments would rebound the innomi-nate into its proper position, usually with a dis-concerting thud. If this method of mobilization inthe wrong direction is continued for any periodof time, one of two things will happen: the jointwill be jammed much more tightly, or it will be-come unstable requiring frequent adjustmentusually at great cost and inconvenience to thepatient.

If at all possible, the shock absorber functionof the sacroiliac joint should be maintained, how-ever some researcher^"^^' have reported ex-cellent relief of pain in the unstable joint following

surgical fusion. If fusion is considered it wouldseem that the joint should be fused in a correctedposition. If it is not corrected before fusion, atorsion strain is built into the pubic symphysisand further instability is likely to occur in thatarea."There is presently much too great a tendencyto become method oriented in the treatment ap-proach. Conservative therapists tend to stay withheat and massage not wanting to do more forfear of hurting the patient, but perhaps not doingenough to help the patient either. The acupunc-turists and those practicing shiatsu may not beusing mobilization, or cold, or heat and massagewhen they are indicated. The manual therapistsshould similarly include any appropriate modalityor procedure, even though it may extend thetreatment time somewhat. Everyone shouldquestion the sequence of modalities and whetherthey are appropriate. The key is proper evalua-tion of the problem and then becoming problemoriented, adapting the methods to the problemrather than the problem to the method.SUMMARY

Pain in the low back is commonly precipitatedwhen an individual leans forward to performsome task and fails to support his anterior pelviswith his abdominal muscles. The resultant ante-rior rotation of the innominate(.$ on the sacrummay result in fixation, acute pain and an apparentlengthening of the leg(s). It is more commonbilaterally, but frequently occurs on just oneside.

The apparent lengthening of the leg(@ is aresult of the alteration of relationship betweenthe sacroiliac joints and the acetabulae. Thelengthening of the leg(s) results in a lengtheningof the sciatic nerve which frequently causes asciatic neuritis.

Flexion of the innominate(s) on the sacrum byflexion of the knee to the ipsilateral axilla re-leases the fixation, relieves the pain, appears toshorten the leg and takes the stretch off of thesciatic nerve. Recurrence is prevented by sup-porting the anterior pelvis with the abdominalmuscles especially when leaning forward. Thecorrective maneuver is safe as it causes minimalflexion. extension, or rotation of the spine.

Occasionally, after the innominate has rotatedanterior ly on the sacrum, it may also jam slightlyvertically, complicating the original anterior dys-function. This requires two maneuvers to correct;


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Summer 1979 DYSFUNCTION OF SACROILIAC JOINT 35manual traction on the leg in the long axis tocorrect the vertical complication and then flexionof the innominate on the sacrum to correct theanterior dysfunction. Relief is usually immediate.

The author thanks Dr. Clark Grimm and the Radiology Departmentof Northern Montana Hospital who provided the roentgenograms andto the American Osteopathic Association and The D.O. for their kindpermission to reprint illustrations and quotations from an originalarticle.

REFERENCES1. Abramson Dl. Tuck S, Lee SW, et al: Comparison of Wet and Dry

Heat in Raising Temperature of Tissues. Arch Phys Med 48:654-661. 1967.

2. Arnell P. Beattie S: Heat and Cold in the Treatment of Hyperto-nicity. J Can Phys Ther Assoc 24:61-67. 1972

3. Bailey HW, Beckwith CG: Short Leg and Spinal Anomalies. TheirIncidence and Effects on Spinal Mechanics. JAOA 36:319-327,1937

4. Beal MC: A Review of the Short-Leg Problem. JAOA 50:109-121, 1950

5. Burton C. Maurer DD: Pain Suppression by TranscutaneousElectronic Stimulation. IEEE Transactions on Biomedical Engi-neering, Vol. BME, no. 2, March 1974, pp 81 88

6. Cailliet R: Neck and Arm Pain. Philadelphia. FA Davis Co. 1964.P 46

7. Cailliet R: Low Back Pain Syndrome. Second Edition. Philadel-phia. FA Davis Co., 19 68

8. Chamberlain, WE: The Symphysis Pubis in the Roentgen Exam-ination of the Sacroi liac Joint. Am J Roentgen01 Radium TherNucl Med 24:621-625, 1930

9. Colachis SC. Jr. Strohm BR: Effects of Intermittent Traction onSeparation of Lumbar Vertebrae. Arch Phys Med 50:251-258,1969

10. Colachis. SC Jr, Worden RE, Bechtol CO, et al: Movement of theSacroiliac Joint in the Adult Male: A Preliminary Report. ArchPhys Med 44:490-498, 1963

11. Coventry MB, Tapper EM: Pelvic Instability. J Bone Joint Surg ,54-A:83-101. 1972

12. Cunningham DJ, cited by Dwight T, et al: Human Anatomy,Including Structure and Development and Practical Considera-tions. Edited by GA Piersol. Philadelphia. JB Lippincott Co..1907, p 346

13. Cyriax J: Manipulation-by Laymen or Physiotherapists? J CanPhysiol Assoc 23:236-238. 1971

14. Danforth MS. Wilson PD: The Anatomy of the Lumbo-SacralRegion in Relation to Sciatic Pain. J Bone Joint Surg 7:109-160. 192515. DeLorme TL: Exercise. Physical Medicine in General Practice.Third Edition. Edited by W Bierman and S Licht. New York. PaulB. Hoeber, Inc. 1952

16. Diagnosing Back Pain: Take the Systematic Route to Causes.

Patient Care 10:22-55 . 197 617. DonTigny RL. Sheldon KW: Simultaneous Use of Heat and Cold

in the Treatment of Muscle Spasm. Arch Phys Med 43:235-237 .1962

18. DonTigny RL: Evaluation. Manipulation and Management of An-terior Dysfunction of the Sacroiliac Joint. DO 14:215-226. 197 3

19. Ducroquet R, Ducroquet J. Ducroquet P: Walking and Limping.A Study of Normal and Pathological Walking. Philadelphia, JBLippincott Co.. 1968

20. Grant JCB: A Method of Anatomy. Descriptive and Deductive.Sixth Edition. Baltimore. Williams 8 Wilkins Co.. 1958

21. Gray H: Anatomy of the Human Body, Twenty-eighth Edition.Edited by CM Goss. Philadelphia, Lea 8 Febiger, 1966

22. Hines TF: Posture. Therapeutic Exercise. Second Edition. Editedby S Licht and EW Johnson. New Haven, Elizabeth Licht. 196 5

23. Kendall HO, Kendall FP, Boynton DA: Posture and Pain. Balti-more, Williams 8 Wilkins Co.. 1952

24. Larson NJ: Sacroiliac and Postural Changes from Anatomic ShortLower Extremity. JAOA 40:88-89, 194 0

25. Loeser JD, Black RG. Christman A: Relief of Pain by Transcuta-neous Stimulation. J Neurosurg 42:308-314, 1975

26. McConnell CP. Teall CC: The Practice of Osteopathy, ThirdEdition. Kirksville. Mo., Journal Printing Co., 1906

27. Mennell JB: The Science and Art of Joint Manipulation. Vol 2,The Spinal Column. Philadelphia. Blakiston Co.. 195 2

28. Mennell JM: Back Pain. Diagnosis and Treatment Using Manip-ulative Techniques. Boston, Little. Brown 8 Co.. 1960

29. Mixter WJ and Barr JS: Rupture of the ln te ~e rt eb ra l isc withInvolvement of the Spinal Canal. N Engl J Med 21 1:210. 1934

30. Nachemson A, Morris JM: In Vivo Measurements of lntradiscalPressure. J Bone Joint Surg 46A:1077, 1964

31. Newton MJ. Lehmkuhl D: Muscle Spindle Response to BodyHeating and Cooling. J Am Phys Ther Assoc 45:91-105, 196 5

32. Norman GF, May A: Sacroiliac Conditions Simulating Interverte-bra1 Disc Syndrome. West J Surg Obstet Gynecol 461-622.1956

33. Norman GF: Sacroiliac Disease and its Relationship to LowerAbdominal Pain. Am J Surg 1 16:54-56. 19 68

34. O'Donoghue, DH: Treatment of Injuries to Athletes. Philadelphia.WB Saunders Co.. 196 2

35. Picaza JA. Cannon BW, Hunter SE, et al: Pain Suppression byPeripheral Nerve Stimulation. Surg Neurol 4:105-114, 197 5

36. Schunke GB: The Anatomy and Development of the Sacro-IliacJoint in Man. Anat Rec 72:313-331. 193 8

37. Shealy CN, Maurer D: Transcutaneous Nerve Stimulation forControl of Pain. Surg Neurol 2:45-47, 1974

38. Smith-Petersen MN: Discussion of Reference 14; published inReference 14

39. Smith-Petersen MN: Arthrodesis of the Sacroiliac Joint. A NewMethod of Approach. J Orthop Surg 3:400-405. 1938

40. Steindler A: Discussion of Reference 14; published in Reference1441. Trotter M: A Common Anatomical Variation in the Sacro-IliacRegion. J Bone Joint Surg 22:293-299. 194 0

42. Wilson JC. Jr: Low Back Pain and Sciatica. A Plea for BetterCare of the Patient. JAMA 200:705-712. 196 7

dysfunction of sij

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