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.
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.
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