The sacroiliac (SI) joint is the joint between the sacrum and the ilium bones. The sacrum supports the spine and is itself supported by the ilium on either side. The SI joint is meant to remain relatively stable as opposed to a highly mobile joint like the shoulder which moves a great deal in order to reposition the arm. The SI joint does move a small amount in order to transfer forces between the body and the legs, acting as a type of shock absorber.1
Figure 1 - Sacroiliac (SI) Joint
We have a right and a left SI joint. The surfaces of the joints have irregular elevations and depressions that results in interlocking of the joint surfaces. There are strong non-elastic connective fibers called ligaments that stabilize the front and back of the joint.1 In addition, there are multiple strong muscle groups that cross over the joint providing additional stability.
Figure 2 - Sacroiliac Ligaments
Figure 3 - Vleeming's Slings
When a patient is diagnosed with SI joint dysfunction, non-surgical treatment is typically recommended as the first-line of treatment and is continued if the patient is continuing to get adequate relief from their symptoms. Non-surgical treatment may include medication, physical therapy including a trial of SI-belting, injections, and radiofrequency ablation. This article will address the physical therapy component of non-surgical treatment, referred to as rehabilitation. Physical therapy may or may not be combined with the other treatments described above.
Pain and altered function of the SI joint that is not related to an inflammatory condition, such as Psoriatic arthritis, or other pathologic process such as tumor or infection, is often referred to as sacroiliac joint dysfunction (SIJD). There is not a universally accepted definition of SIJD, however, SIJD generally refers to pain in the SI joint region that is caused by or results in altered function of the SI joint. There may be either too much or too little joint motion, the ligaments may be too tight or too stiff, the muscles supporting the SI joint could be damaged or not working correctly, there could be too much or too little joint compression, or there could be other factors such as a leg length inequality that lead to abnormal loading of the joint. A patient may have one or more than one of these factors contributing to their pain. SIJD may result in degeneration of the SI joint. This may also lead to pain in the muscles and connective tissues surrounding the joint or that extend from the SI joint to adjacent joints.
Figure 4 - SI Joint Dysfunction
Sacroiliac joint dysfunction is diagnosed with a history and physical examination. A patient with SI joint pain will frequently identify the SI joint as the source of pain by pointing to the posterior superior iliac spine (PSIS) as shown in Figure 5 (Fortin Finger Test).2 Patients will typically have multiple positive findings on provocative testing of the SI joint (tests that load the painful SI joint).3
Figure 5 - Fortin Finger Test Figure 6 - SI Joint (green X)
Figure 7 - SI Joint Provocative Tests
Non-surgical treatment of the SI joint isn’t limited to treatment of the joint itself, but also includes treatment of contributing factors that can lead to dysfunction and pain both at the SI joint and in the adjacent muscles, ligaments and joints. As patients with SIJD can be quite different (a 35-year old post- partum female as opposed to a 65-year old male with multiple prior lumbar fusions) there is not a single treatment plan that is right for every patient. The best way to treat SI joint pain with rehabilitation is to identify and then treat the underlying soft tissue impairments. This should be accompanied by symptom relief so that treatment is well tolerated. This treatment plan assumes that the healthcare practitioner has already ruled out pain associated with pathological processes including inflammatory arthritis, infections, tumors and acute fractures with blood tests and diagnostic tests such as x-rays, CAT scans, MRIs, etc.
Rehabilitation for the SI Joint
Physical therapy, as a profession, is not uniform and there are different schools of thought regarding treatment of SI joint disorders. However, the goals of rehabilitation for SI joint pain typically include:
- Return the SI joint it to its normal position4 and maintain this position. Optimal SI joint function occurs with the SI Joint in neutral (mid-range) position.5-13
- Restore optimal alignment of the lumbar spine, sacroiliac joint and hip joints
- Optimize functional stability of the lumbopelvic region by restoring normal function of the supporting muscles
Prior to treatment the physical therapist performs a thorough evaluation and identifies problems in the following areas that may affect the three goals above:
- General Deconditioning
- Weakness of Stabilizing (Core) Musculature
- Imbalance of muscle length on the muscles that attach to the legs or cross the trunk and pelvis
- Imbalance in muscle strength of the muscles that attach to the legs or cross the trunk and pelvis
- Problems with function, position or motion in the joints above and below the SI joint including the hips and spine directly above and below but also including joints at a distance like the ankle.
- Restriction or scarring in the muscles or tissues that overly or attach to the SI joint
- Poor postural patterns
- Poor and asymmetrical movement patterns with daily activities
- Abnormal or asymmetric walking patterns
- Lack of control of the muscles that coordinate to stabilize the lower back and pelvic region (often called motor control)
- Pain in soft tissues and joints other than and including the SI joint.
After the evaluation, the physical therapist will create a treatment plan to address the deficits described above. When creating this treatment plan, the physical therapist takes into consideration the patient’s functional goals. Functional goals are the activities that the patient needs to perform so that they can perform their self-care, occupational and recreational activities in a manner such that they can live with their SI joint dysfunction.
There is very little published clinical evidence for any one specific treatment technique for SI joint dysfunction. Physical therapy is a profession, rather than a specific treatment. As such, physical therapists are educated to identify and treat impairments identified during the evaluation based on published research and what is termed “best practice”. The underlying impairments described above are identified and then treated. The goal is to achieve the three functional goals and ultimately assist the patient in achieving pain-free function with their daily activities.
One of the most important aspects of an effective treatment program is patient education. The patient should be educated as to the potential cause(s) of the SI joint dysfunction They should also be educated on how they need to be an active participant in their care. This includes following recommendations to change the way the patient positions themselves, moves during daily self-care and recreational activities, including methods to independently reduce their pain. This may include application of heat or ice, resting when advised, and performing specific exercises.
The patient will frequently be given a home exercise program. This program will be specifically designed to address the impairments of each individual patient. Effective and frequent communication between the patient and physical therapist is important to assure the exercises are within the patient’s pain tolerance and abilities.
These are the parts of treatment that may help with the alleviation of SI joint dysfunction.
Modification of Activities of Daily Living (ADLs)
- The physical therapist may specifically focus on activities that create or worsen symptoms. These activities typically involve repetitive twisting and asymmetrical motions. They will replace these activities or modify them to eliminate potential strain on the SI joint or the development of impairments in muscle length/strength and joint mobility above, at and below the SI joint.
Patient education regarding maintaining optimal alignment with positioning, posture and body mechanics
- The physical therapist will educate the patient regarding the best way to sit, stand, move, sleep, and perform daily activities to prevent body positions that may decrease the ability of the core muscles to function resulting in additional strain on the SI joint. The suggestions may include avoidance of:
- Sitting in asymmetric positions with knees crossed or shifted to one side
- Standing with the knees locked (hyperextended) and weight shifted to one side
- Twisting to one side for long periods or repeatedly: It is better to move the entire torso and prevent this strain on the SI joint especially in the spine if fused of the patient has stiff hips that don’t rotate well
- Sleeping on one side with lack of support under the waist and between the knees. This allows the trunk to bend to one side and may put the spine and hip in an asymmetric position for long periods leading to muscle stiffness/shortness and strain on the SI joint. The PT may advise the patient in the use of pillows or supports to make this position more symmetric.
Instruction in Stabilization (Core Strengthening) Exercises
- Specific focus on timing and engagement of local and global core stabilization muscles12,14-16
- The physical therapist will help the patient identify and contract the core muscles in the pelvic and trunk regions with the use of feedback. This may be visual by using a mirror, tactile by using touch, or with feedback from a machine after sensors are applied to the core muscles.
- As treatment progresses, the physical therapist will progress these exercises and make them more challenging and incorporate them into daily motions that the patient requires to function at home, at work and with their recreational activities
- The physical therapist may also recommend an SI band or belt for temporary use to compress the SI joints and provide external stability until the patient’s core muscle strength improves and/or to help with treatment tolerance (pain relief).
Achieve normal muscle strength balance (It is important for there to be a balance in the strength of muscles that stabilize the SI joint)17-20
- The PT will instruct the patient in exercises to address any muscles that have weakened because of chronic SI joint pain. This includes the Gluteus Medius muscle which often becomes weak on the painful side. This muscle may affect balance while walking.
- The PT may instruct the patient to strengthen muscles that affect the position or the mobility of the SI joint These muscles may be in the legs, trunk, or hip region. The goal is to have equal muscle strength on each side of the joint.
Achieve normal muscle length balance17-21
- The physical therapist may instruct the patient in stretches to lengthen muscles that attach to the ilium and sacrum directly and/or indirectly, especially those that limit hip internal rotation. Research has found that patients with sacroiliac pain or dysfunction may lack full internal rotation (movement inward) of the hip on the affected side. This will also prevent a short muscle on one side of the joint from affecting joint position and/or motion.
Joint and soft tissue restriction mobilization and manipulation as needed
- The physical therapist may use manual (hands-on) techniques to improve the mobility of the muscles and connective tissue surrounding, attaching to or covering the SI joint or apply them to the joint itself. There is a great variety in the types of techniques used based on that therapist’s training but the goal is to restore normal movement in the tissue and normal position and mobility of the joint.
- The physical therapist may consider manual treatment of the joints above and below the SI joint as far up as the thoracic spine (spinal section attached to ribs) and as far down as the ankle. An ankle that doesn’t lift the foot normally may cause a change in the way a person lifts the pelvis and may change the way the SIJ moves. A stiff thoracic spine may require that the patient to move their SI joint more than they should to compensate
Manual techniques and modalities to address myofascial pain and spasm
- The physical therapist may use manual techniques and modalities to reduce the muscle and connective tissue pain associated with the SI joint condition. They may achieve this by using techniques such as soft tissue mobilization, massage and work to eliminate tender areas in the tissue called trigger points. They may also use modalities such as application of heat, cold, ultrasound, laser and other newer methods to reduce pain in the affected tissue.
Balance assessment and training
- Long term pain in the sacroiliac joint may cause an imbalance in the muscles or a stiffness in the surrounding joints that may affect the patient’s balance. The therapist, may develop a program to address the underlying cause of these balance issues. They may also use specific balance training exercises.
- Pain in the SI joint and/or dysfunction may alter the patient’s gait (walking) pattern. The patient may take a shorter step, elevate the painful side leg using the trunk muscles and may hold the leg on the painful side in a turned-out position. As the patient’s symptoms improve, the physical therapist will assist with educating the patient to eliminate these gait alterations as they may lead to additional pain or dysfunction at, above or below the SI joint.
Regain or maintain cardiovascular health
- Long term pain and/or dysfunction at the SI joint may inhibit a patient’s ability to participate in aerobic activity. Aerobic activity such as walking, jogging, rowing, biking, swimming, or using an elliptical machine is important to maintain a healthy heart and lungs (cardiovascular system). A physical therapist can assist with determining the best aerobic activities to maintain cardiovascular health without putting excessive stress on the symptomatic SI joint.
Most patients notice some improvement in their symptoms within the first several physical therapy visits and may continue to improve until they achieve pain free function. If the patient does not have adequate improvement in their symptoms with rehabilitation and other non-surgical treatment methods within 6 months, then additional evaluation and treatment may be indicated.
IMPORTANT NOTE: The information herein is intended to help create awareness about Rehabilitation for SI Joint Pain and/or Dysfunction. Please note that information contained herein is not medical advice. It should not be used as a substitute for speaking with your physician. Always talk with your physician about diagnosis and treatment information.
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Figure 1 image credit : Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. - Own work image