DEFINITION OF SACROILIAC JOINT DYSFUNCTION

SIJ dysfunction is defined as altered mobility of the SIJ/pelvic structure per passive accessory motion tests, also named Springing with Awareness, which is a specific manner of performing spring tests. There is altered ligament and soft tissue tone such that hypermobility and hypomobility oftentimes co-exist, though they are typically very responsive to appropriate intervention. Oftentimes the posterior musculoskeletal complex is injured which also involves the ligamentous complex including the iliolumbar, dorsal SI ligaments (short and long) and sacrospinous and sacrotuberous. This model does not require that “the ilium is rotated on the sacrum, or the opposite”, in fact; oftentimes this simply is not the case per thorough research detailed elsewhere. Many times the restriction is extrinsic, and sometimes, yes; there is a true shift within the SIJ and symphysis pubis, these are simply much less common than the typical pelvic asymmetries that involve the pelvis moving on and with the hips in an asymmetrical manner.

Sometimes pain is not present as this joint is designed to tolerate large forces. When pain is present, it is typically below the belt line and overlying the SIJ into the buttock, posterior thigh and towards the trochanter and inguinal area. The spring tests are performed with the client’s body in stable positions. The tests are used to evaluate passive accessory motion. They are used to determine if hypermobility or hypomobility is present. The pelvis may or may not be symmetrical. In other words, a symmetrical pelvis can present with hypomobility or hypermobility that is treatable. SIJ dysfunction may also have altered proximal soft tissues, especially if asymmetry is present. The literature describes a fairly unique pain pattern with SIJD, however this model is a biomechanical model, and many more clients have treatable pelvic asymmetry that is relevant to the concept of prevention and optimizing biomechanical function. Pain does not have to be present in order to have SIJ movement dysfunction.  The presence of SIJD implies that the hips, the pelvis as a solitary structure, (such as when loaded in stance, in which SIJ motion is not occurring), and the lumbar spine all participate.  In truth, at least over time, the whole body participates with adaptations and compensations.

The term lumbo-pelvic-hip dysfunction is so much better than sacroiliac joint dysfunction (SIJD). This term brings awareness to the lumbar component and the pelvic component, and the hip rather than bringing focus to the solitary sacroiliac. I appreciate that there exists some literature in which the pain pattern for so-called SIJD is distinctly different from that of lumbar dysfunction. However, this is based on injections into the SIJ which are very problematic for a variety of reasons (please see my chapter on sacral torsion which details the problems with the pain model).  There is literature that supports the use of pain provocation tests as diagnostic of SIJD. Again, this is problematic on several levels. These tests do correlate well when used as a group and correlate with a positive response to SIJ injection, sometimes referred to as a “gold standard.” It is not a gold standard.

Murakami’s remarkable injection study too oftentimes is ignored. He notes that repeat injection reduces positive response (pain relief) in the SIJ by 50% and it continues downward with additional injections. Oftentimes there is an identified rent in the anterior capsule such that injection media leaks onto the lumbar plexus. Further to that, the nerve supply to the anterior SIJ, capsule and ligaments is L2-L3-L4, and the posterior capsule and ligaments is L5-S1-S2 and S3 (partial). Thus, any pain syndrome that causes referred pain may be reduced by injection into the SIJ by reducing the overall afferent input into the spinal cord. Murakami found that a small percentage responded well to injection into the SIJ as compared to posterior intra-articular injections, significantly so. Thus, it appears that SIJD is a posterior soft tissue phenomenon with respect to pain generators.

The cluster of SIJ pain provocation tests can easily be over-interpreted. The Hesch Method suggest that oftentimes these may be negative especially as a group, and yet there may be biomechanical dysfunction in the lumbopelvic-hip complex that is worthy of treatment. This model is primarily a biomechanical model, but does respect pain. The manner in which these tests are performed is at times such as in research and in protocols; performed the very same way in all patients. This can give false negatives and false positives. The Hesch Institute endorses a thorough lumbar and hip screen prior to any direct treatment to the SIJ. The Institute propounds that these tests need to be individualized for each patient in order to achieve the ideal angle and the ideal amount of force to isolate the SIJ, including the posterior soft tissues, especially ligaments. The clinician can palpate just medial to the PSIS on one side when performing each pain provocation test.

The problem of SIJ instability is another, a completely other problem. It is most unfortunate that it seems to be the default acceleration of failed response to a diagnosis of “SIJD.” Meaning that if they do not respond to usual interventions for SIJD, then the assumption becomes that their case is one of instability, which ups the ante in terms of invasive procedures and this can include surgery. I see some of these failures, failed response to surgical intervention, and I am unimpressed with the limited diagnostic process. I have encouraged additional workup for some who were in the process of getting worked up for surgery, I have had some that I discouraged surgery go forth and have surgical stabilization of the SIJ and have failed response. I had one case with an already fused SIJ per CT scan (multiple images) in which there was a hardware breach into the lower right SIJ. My input was not adequate, she went on to have this fused SIJ “surgically stabilized’ and went on to develop other symptoms. I have made recommendation for work up for consideration of SIJ stabilization surgery, but much less frequently than is being done in some parts of the country.

My first case was in 1984, very successful response after failed response to a poster lumbar fusion, then to an anterior lumbar fusion; still using a walker with wheels with the same SIJ pain syndrome, a year later. She threw the walker away after SIJ fusion and participated in race walks for charity. The surgical recommendation should not be made lightly, and SIJ surgery should NOT be the new answer for any and all types of failed back syndrome or even failed SIJD rehab syndrome. Sadly, the marketing machine marches on like a juggernaut. Only after very thorough testing, and very thorough treatment failure, should this be given consideration. When I see these cases (before or after) I thoroughly question them regarding the diagnostic process and I sadly report that I am appalled. Severe lumbar pathology, hip dysplasia and impingement syndromes have been part of these misdiagnosed surgical SIJD cases.

There is very good objective testing being done for cases of traumatic instability of the pelvic joints which may or may not include bony fracture.  I have written on this elsewhere and I hope that this level of objectivity will makes its way into that wide gray zone of chronic SIJD and so-called SIJ instability.

SIJ instability is not the same as SIJD, not the same as lumbopelvic-hip dysfunction. There is no such thing as isolated SIJD, it always co-exists with lumbopelvic-hip dysfunction. The psychosocial phenomenon of being under-acknowledged, underdiagnosed for a long time and then being given acknowledgement as having a valid and severe diagnosis of SIJD makes this population very vulnerable. It should be a degree of dysfunction. Perhaps a better diagnostic approach would be stated similar to “primary SIJD with co-existing lumbopelvic-hip dysfunction”.  Would this, could this improve diagnosis and treatment, and help prevent unnecessary permanent function-altering surgeries? Could it improve surgical outcomes for those who truly do have true instability and are in need of surgical stabilization. I think so I hope so. These patients deserve such.  Whenever the term “SIJD” is encouraged, we should think “lumbo-pelvic-hip dysfunction.”  I hope that this book reflects that.

Jerry Hesch

President Hesch Institute - Las Vegas Manual Therapy

Regarding the costocorporal and costotransverse joints one of the most painful rib fixations is a medially compressed rib. It can be released slowly and gently with an anterior glide sustained for 30 seconds and then adding a lateral vector along the angle of the rib. Best is to actually add a slight lateral vector. The rib can of course do the opposite, rather common at upper to upper-mid from posture, habit, work, sitting, etc.

 The next most painful would be inferior fixation, though they can be fixated superiorly, tested just lateral to the transverse process. This is not a bucket handle dysfunction, they are tested laterally and are subtle if tested proximally.

 Lastly, the thoracic segments, if mobilized or manipulated typically correct a side-bending restriction and a rotation can remain, only discovered with medial spring test at spinous process on each side. If restricted stack side bending above and below and gentle rotation. If spinous process rotated to the right and does not spring right to left, thenside bending and rotation is to the right because the front of the vertebrae is rotated left moving spinous process to the right.

 Again, I favor gentle forces and contact the right side of spinous process and the segment above and below and lean in and maintain the force for 2 minutes.

 I do teach courses on very gentle mobilization throughout the body.

 Hope this is helpful, can clarify, shoot video etc.

 Jerry Hesch

 www.HeschInstitute.com

PULL OUTS FROM THE SACRAL TORSION CHAPTER by Jerry Hesch

From Hesch J. Sacral torsion about an oblique axis: a new approach to an old problem. Dynamic Body. Dalton E., ed. 2011:190-231.

Part 1

   These are parts of the text that were highlighted and placed in a box throughout the chapter to promote interest in the content. Not all of these made it to the final printed text, but are included nonetheless.

Springing used as a passive accessory motion test (and grading system) is part of a basic skill set that should be accessible to manually-oriented clinicians.

With torsion, one sacral quadrant will be prominent. In the presence of a sacral torsion the sacrum will be most asymmetrical at only one side of the sacral base or apex. In the most common torsion, the left lower sacral quadrant is prominent.

A frequently reported sacral movement dysfunction is named sacral torsion about an oblique axis, which is also known as sacral torsion, or simply as torsion. Torsions do meet the above definition of SIJD, and are the focus of this chapter.

Torsions frequently coexist with low back pain, making them difficult to isolate as the underlying issue.

This chapter will present an alternate model of sacral torsion theory.

If sacral torsion theory is to be integrated into a larger segment of clinical practice, then a reasonably less complex model is long overdue.

Torsions can be understood with small changes in nomenclature and in the method of screening.

The new nomenclature seems to be much easier to visualize and understand, and treatment is implied in the descriptive term.

The following terminology is suggested as the most ideal improvement over the traditional.  Note that the treatment technique is implied in the description.  Specifically, the prominent and blocked quadrant is the one where the mobilizing force is applied.

    Posterior Left Lower Sacral Quadrant with Blocked P-A Spring, instead of Left on Left Sacral Torsion, or Left Rotation on Left Upper Oblique Axis.

    Posterior Left Upper Sacral Quadrant with Blocked P-A Spring, instead of Left on Right Sacral Torsion, or Left Rotation on Right Upper Oblique Axis.

    Posterior Right Upper Sacral Quadrant with Blocked P-A Spring, instead of Right on Left Sacral Torsion, or Right Rotation on Left Upper Oblique Axis.

Posterior Right Lower Sacral Quadrant with Blocked P-A Spring, instead of Right on Right Sacral Torsion, or Right Rotation on Right Upper Oblique Axis.

The bony pelvis and the SIJ are not one-and-the- same, and their distinctions should not be blurred.

The creative clinician needs to bridge the two topics of so-called SIJD and pathomechanics of the pelvis.

Treatment is unnecessarily complex

Part 2

The treatment technique for torsion can be rather complex.  The following is a typical treatment sequence for a left on left sacral torsion, using muscle energy technique:[i]

1. Patient in left lateral Sims position, close to edge of table, right arm over side of table, left arm behind and on table.

2. Operator faces patient, palpates lumbosacral junction.

3. Operator flexes patient’s legs (knees and feet together) until motion felt at sacral side of LS junction.

4. Patient’s legs maintained in this position against operator’s abdomen, hip or thigh.

5. Operator’s right hand now moved to patient’s right shoulder. As patient exhales, instructed to reach to floor with right hand. Operator maintains pressure on right shoulder. Repeat until L5 is rotated to left.

6. Operator’s left hand moves to patient’s feet, which are placed off edge of table, and pressed downward.

7. Patient instructed to push feet to ceiling as operator maintains pressure on patient’s feet and monitors L5 junction.

8. When patient relaxes, slack is taken up by operator with left hand.

9. Repeat 7 two or three times. (Right sacral base should be felt to move posteriorly).

10. Retest! Note: a variation allows the operator to sit on the table with the left hand monitoring the sacral base while the right hand resists elevation of patient’s legs toward ceiling.

I find the above positioning to be a challenge for both patient and practitioner.

I developed a model of torsion evaluation and treatment that made sense to me, and one which I could readily apply on a daily basis.

In addition to better teaching tools, students need more time to acquire manual skills.

Although torsions have been described as being a normal motion that occurs during the gait cycle that concept has been discouraged by some clinicians, who essentially dismiss the overall concept of SIJD.

It may be that the sacrum does not move in torsion during the gait cycle.

The bony pelvis does move on the femoral heads in standing, and asymmetry of the pelvic landmarks does not validate that the SIJ is the cause of that asymmetry.  That belief has been negated and reinterpretation is timely.

A very relevant and perhaps obscure fact is that none of these “objective radiological studies” measured the presence or absence of concomitant motion in the symphysis pubis, which by design; always occurs with SIJ motion.

Perhaps the joint does in fact function with compression and recoil throughout much of the articular surfaces during normal motions of the body, whereas end-range positions with large passive forces are required to induce true joint fixation.

Part 3

SIJD in the female is a valid paradigm due to gender-specific anatomy and physiology, includinghormonal influences, pregnancy and birth mechanics, which of course can be enhanced by passive trauma or repetitive strain in the adult female.  Therefore, clinicians should become very skilled in treating this population.

Health practitioners sometimes tend to medicalize SIJD diagnoses, when oftentimes, rational early intervention can provide significant and lasting benefit.

In this example, a functional activity screening would not have been as informative as hands-on passive joint movement testing, typically referred to as spring/micro-motion testing.  As shown in this example, hands-on screening, including passive spring/micro-motion (joint motion) testing was necessary, in spite of prevailing clinical dogma.

SIJ mobilization or manipulation can certainly have a clinical effect, yet the treatment may have less specificity than is purported, and affect the surrounding soft tissues rather than reposition the joint.

The asymmetry of sacral sulcus depth needs to be addressed within several contexts, and ILA asymmetry alone is a poor indicator of mechanical SIJD.

The fluoroscopy video seems to clearly convey that motion transfers through the SIJ, and it is functionally relevant and of normative anatomy, physiology, and biomechanics.

The fact that muscle length has a significant influence on ligament tone in several regions of the body, including the pelvis, is a very under-appreciated clinical fact.

Initially this method can seem challenging, but is easily learned with a little practice while slowly reading the sequence with your hands on an anatomical model, or a volunteer.

Treatment will consist of applying approximately 20# of force.  This will be maintained for two minutes, and the sacrum will typically release within that time frame, such that repeat testing will indicate normal mobility.

Thus, it is easy to encounter weak muscle groups that are reflexively inhibited, although not intrinsically weak.  With this treatment paradigm, removing the inhibition is the first order of care.  To do otherwise unnecessarily protracts care.

“Dogma dulls the wits… it is better to let the joints (and somatic structures) speak for themselves, rather than dictate to the joint how it is to behave based on various theories.”   Gregory Grieve

We are screening for treatable motion that is blocked, not allowing forces to travel through the SIJ, as opposed to the illusion that we can discern motion loss in the SIJ.

I find the traditional springing portion of the sacral evaluation difficult to use, as it only gives me half of the movement information – the forward portion.

Noteworthy is the observation that pathomechanics and treatment of the pelvis and pelvic joints is not always a natural extension of normal mechanics, and thus there is a knowledge gap in the education of biomechanically-based health care practitioners.

Springing is part of a basic skill set that should be accessible to manually-oriented clinicians.

Palpation and Spring Test Practice

http://www.youtube.com/playlist?list=PLktlS7HfJ-YpqMDYB7hoowhko2-leyjgn

Introduction to Hesch Lumbopelvic Workbook

http://www.youtube.com/watch?v=Z87u9Y-cO7U&feature=youtube_gdata_player

http://www.youtube.com/watch?v=qrpimagzbgI&feature=youtube_gdata_player

Hesch Institute Web Site

http://www.youtube.com/watch?v=7Wiu91bO8N4&feature=youtube_gdata_player