Sacroiliac joint (SIJ) dysfunction treatment

In the second of a two-part series, David Joyce sets out a treatment strategy for sacroiliac joint (SIJ) dysfunction

Last month, we looked at the way the well-functioning sacroiliac joint achieves the stability we need to run and jump, through the mechanisms of ‘form closure’ (anatomical fit) and ‘force closure’ (active compression provided by the neuromuscular system). We covered various clinical signs for sacroiliac joint (SIJ) dysfunction and pain(1), and looked at two assessment tests in particular – the active straight leg raise and the stork test. In this second article, we concentrate on treatment strategies for sacroiliac joint (SIJ) pain.

Acute phase

The initial aim of the therapist will be to reassure the client and protect the injured part to ensure optimal healing. It can be very helpful to use an outcome measure at the outset, repeated at the end of rehab, to give both therapist and client measurable assessments of the programme’s success. There is no single perfect tool forsacroiliac joint (SIJ) outcome measurement, but the Oswestry Disability Index or the Quebec Back Pain Disability Score are both good (see box overleaf).

Education: As always, it is important to educate the client about the nature of the problem, in order to reduce their anxiety – and therefore their pain levels. It will also help with their compliance. In the case of sacroiliac joint (SIJ) pain, the therapist should explain the anatomy of the joint, so that the client starts to understand why they get pain when ascending stairs or landing after a tennis serve, and why they may need to cease running and jumping for the time being.

Pain relief: Manual therapy techniques that reduce the stretching stress on the pelvic ligaments can be very effective for relieving pain. Two of the most commonly provoked ligaments are the sacrotuberous ligament and the long dorsal sacroiliac ligament. The sacrotuberous ligament is tensioned when the pelvis is tilted posteriorly. Anterior tilting of the pelvis on a therapy ball can help to quieten this one down. The long dorsal sacroiliac ligament is tensioned in anterior pelvic tilt. Stepping up on to a chair (thereby fixing the hip in flexion) with active posterior pelvic tilt and trunk flexion will help decrease the tension on this ligament and reduce pain. These are lovely exercises for the client to complete at home.

Acupuncture can be very useful in the acute stage and the application of a cold pack over the sacrum is often helpful as it can slow down the conduction of nociceptive information through the nerve fibres. A pelvic belt or rigid sports strapping may provide some compressive support. The therapist may also need to liaise with GP or specialist for advice on analgesic prescription.

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Stretching: Muscle spasm form part of ‘body logic’. The body seeks to augment its stability in the damaged area by increasing the tone of some of the longer muscles. Unfortunately these muscles are physiologically designed as prime movers or ‘accelerators’ and tend to spasm if used in a dual role of movement and support. This muscle spasm can make the client’s pain experience more miserable, but if the injury is acute or traumatic, sometimes getting rid of this spasm can be disadvantageous, as it may be the only basis of support they have. I tend to leave the stretching and muscle release until the situation has settled down a bit.

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Sacroiliac joint (SIJ) dysfunction is often found in combination with lumbar spine problems. The lumbar spine must be assessed and any dysfunction addressed. That’s a different ball game and is beyond the scope of this article.

Breathing: We know that sacroiliac joint (SIJ) dysfunction can alter breathing patterns(2). It appears that the brain has trouble coordinating respiration and pelvic support when sacroiliac joint (SIJ) pain is present. Thankfully the brain devotes its resources to the task of keeping our lungs active. We, as clinicians, need to address the coordination of breathing with maintenance of pelvic stability.

We need to encourage the normal breathing pattern and limit the use of accessory respiratory muscles: look for the clavicles rising too much during quiet breathing or breath-holding when moving the limbs. The sacroiliac joint (SIJ) client will often alter their breathing pattern when trying to complete some of the more challenging tasks later on in their rehab – another important cue to look out for.

Motor control retraining: Motor control involves low threshold activation and endurance training of local and global stability muscles. The most important local stabilisers are:

* transversus abdominis (whose fibre orientation is highly specific for compressing the SIJ)

* pelvic floor slings

* internal obliques

* deep psoas major

* multifidus.

These muscles provide the ‘base for the crane’. If the base is wobbly, the crane cannot lift much (hence the positive ASLR test as discussed in Part 1).

Research shows that these muscles are not failing to contract, but that they lose their anticipatory firing ability to prepare the pelvis for impending load(2). It is this anticipatory function that must be restored.

There is debate about the right moment to start stability retraining. Some believe that the loss of lumbopelvic muscle contraction is the result of pain and that it is folly to begin instructing the client before there is adequate pain relief. My own belief is that this aspect needs to be broached with the client early and reinforced in subsequent sessions.

I also believe the client needs to leave their first treatment session with some feeling of muscular control of their wayward pelvis. It is highly likely that they will be inefficiently bracing to begin with, but this can be refined subsequently. It’s important to tell the client that these kinds of low-threshold lumbopelvic control exercises are unlikely to fix their problem instantly, but they provide the foundations for later progress.

Sub acute phase

Once the pain has died down, trigger points can be safely addressed. Massage and the application of a heat pack over localised areas of muscle spasm (for example, hamstrings and quadratus lumborum) can help. The client can be sent home with a programme of stretches, which may include any or all of adductor, hamstrings, hip flexor, gluteal and quads stretches. Not all muscles need to be stretched and it is possible for a muscle to be too long and therefore force-inefficient. Let your assessment findings be your guide.

Muscle energy techniques: METs are very effective in correcting pelvic positional faults. They rely on the phenomenon that muscles are at their most relaxed directly after they have contracted. This can be used to advantage to subtly manually reposition a joint which was mal-located. For example, a common feature of sacroiliac joint (SIJ) dysfunction is an anteriorly rotated ilium, often maintained by the quadriceps. The MET for this is to get the client gently to contract their rectus femoris isometrically against the therapist’s manual resistance. This contraction is held for six to eight seconds and then relaxed. During the relaxation, the therapist takes the opportunity to posteriorly glide the ilium into an anatomical position. This can sometimes take several repetitions and needs to be followed up with home stretches. The same technique can be used with many other pelvic alignment faults.

Motor control: Once the client can cocontract their transversus abdominis, multifidis and pelvic floor, while being able to breathe appropriately, it is time to move them on to more challenging tasks, involving holding the contraction while moving their limbs. This can be done in almost any position and can be further progressed by adding elements of speed and resistance to limb movements, or by making the supporting surface less stable (with a therapy ball or foam roller, for instance) to challenge their central control. When designing exercises, the therapist should aim to get the client into a functional weightbearing position as soon as possible.

Resistance training: This needs to be broken down into its components of strength, power and endurance. The training principle of specificity applies, and again, the therapist’s programme design should reflect this. Use the guide below when designing a programme.

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There is no evidence that low-load training corrects strength deficits in the limbs or ‘core’ muscles; nor is there compelling proof that motor control training is a pre-requisite for strength training.

Core strength training results in co-contraction of all regional muscles. It emphasises rigidity rather than motor control and is an integral part of training to tolerate loaded activity. As such it should be part of an integrated strengthening programme.

Starting strength training early works well(3), but given that the patient is likely to have problems transferring vertical loads, initial training may need to be prone or supine, using pulleys or resistance bands. Exercises such as the plank, side plank, lat pull downs and resisted hip adduction all activate and strengthen key muscles that add to pelvic compression.

Late phase rehab

Progression: A gradual increase in vertical loading can be introduced as tolerated. This may involve half lunges (eg, to 45 degrees) and step ups. The therapist should bring the client’s attention to activation of their lumbopelvic supporting ‘slings’ as they perform these tasks. This will help retrain the brain to an adaptive muscle pattern. As the client improves, the complexity and load of these tasks can be increased. Incorporating resistance exercises that combine arm and leg movement as well as trunk co-contraction replicates functional tasks such as serving in tennis. This can be achieved by performing a step-up while simultaneously performing a bilateral resistance band lat pulldown (see Figures 1a and 1b, p3).

Once the client is walking well and stairs are not a problem, we can start to increase the vertical load. Gentle jogging can begin but if this is provocative, a stepper or cross trainer is a useful intermediary.

Plyometric exercises that involve multijoint movements performed at speed comprise the end stage of rehab and should only be started when the client is completely pain free and able to run without difficulty. This could involve a variety of jumping and hopping tasks that challenge the ability of the pelvis safely to transfer such high vertical loads.

Summary

Rehabilitation of the sacroiliac joint (SIJ) is still shrouded in mystery, but it doesn’t need to be. If the presenting problem is assessed properly and treated along the same lines as for say, an ankle or any other joint, you won’t go far wrong. The need to individualise the rehabilitation is obvious. With a systematic plan, and an individualised treatment approach, the scourge of sacroiliac joint (SIJ) pain will be defeated and you will have your client back at squash, competing in the triple jump or just running around the block.

References

1. O’Sullivan PB, Beales DJ, Beetham JA, Cripps J, Graf F, Lin IB et al. (2002). ‘Altered Motor Control Strategies in Subjects with Sacroiliac Joint Pain During the Active Straight-leg-raise Test’. Spine 27, E1-E8.

2. Hungerford B, Gilleard W, and Hodges P (2003). ‘Evidence of Altered Lumbopelvic Muscle Recruitment in the Presence of Sacroiliac Joint pain’. Spine28, 1593-1600.

3.Stuge B, Laerum E, Kirkesola G, and Vøllestad N (2004). ‘The Efficacy of a Treatment Program Focusing on Specific Stabilising Exercises for Pelvic Girdle Pain after Pregnancy: A Randomised Controlled Trial’. Spine, 29(4), 351-359