Sacroiliac joint dysfunction is a highly debated and controversial source of low back and buttock pain in the sports, with it often being accused of moving too little (i.e., hypomobility), moving too much (i.e., hypermobility), or even medically subluxating (i.e., an incomplete or partial dislocation of a joint) or “popping out of position”. The sacroiliac joint is a broad term and is often used as a scapegoat for low back and buttock pain that has no clear diagnosis. Thus, management can be a challenging task and mutlimodal interventions are often required.
What is sacroiliac joint dysfunction?
The sacroiliac joint is the joint between the sacrum and the ilium bones of the pelvis, which are connected by strong ligaments. The sacrum supports the spine and is supported in turn by an ilium on each side. The sacroiliac joints are strong, weight transferral synovial plane joints with irregular connecting surfaces that interlock the two bones. Humans have two sacroiliac joints (i.e., left and right) that often very similar in structure to one another, but are highly variable from person to person.
Sacroiliac joint dysfunction is a mechanical diagnosis of exclusion–when there is no clear diagnosis, clinicians will often put it down to the sacroiliac joint. It is vague term, which does little to provide clinical certainty or direction. It is described as a condition in which the sacroiliac joint is mechanically obstructed (i.e., locked into a specific movement pattern or direction), medically subluxated in an abnormal position due to joint hypermobility or hypomobility.
Prevalence and epidemiology of sacroiliac joint dysfunction
The prevalence of sacroiliac joint dysfunction varies greatly in the literature, with estimates ranging between 15-30% and even has high as 50% in certain sporting populations.
Women being 3 or 4 times more likely to be affected than men. One of the reasons women appear to be more affected is due to the biomechanical and biochemical changes that occur during pregnancy and childbirth. The hormone relaxin is secreted by the placenta and causes the cervix to dilate and prepares the uterus for the action of oxytocin during labour. This biochemical change, along with the trauma of childbirth, stretches ligaments, muscles and fascia of the pelvis and low back, causing marked biomechanical changes to the sacroiliac joint and surrounding structures. Other reasons include that fact that on average, women have wider hips than men, which incresses torque across the sacroliac joint when walking or running, and the sacroiliac joint surface itself and shallower than men’s, which also reduced joint stability.
However, the true prevalence of sacroiliac joint dysfunction is extremely difficult to establish, not only due to the complex anatomy of the joint with its many ligaments and myofascial structures that can be a source of pain, but also due to the multifactorial nature of low back pain and buttock pain.
What are the causes of sacroiliac joint dysfunction?
There is controversy and disagreement on how and why the sacroiliac joint causes pain. It is commonly thought that poor spinal or pelvis positions or poor posture may be factors in sacroiliac joint dysfunction, with excessive anterior or posterior tilt of the pelvis adversely stressing and sensitising either the joint itself, its many ligaments or the myofascial tissue across it. However, there is no evidence that spinal or pelvic positions or postures have any association with pain or incidence of injury.
Poor pelvic floor strength, abdominal or lumbar spine muscles is also often proposed, in the belief that it allows for excessive sacroiliac joint movement and shearing forces. However, there are doubts around this commonly held theory. There is no correlation between excessive movement of the sacroiliac joint and pelvic pain–it is even questionable whether excessive movement actually occurs at all, even in those diagnosed with widespread hypermobility joint syndromes like Marfans and Ehlers Danlos syndromes.
Furthermore, despite claims for the need to improve trunk and pelvic strength to increase the stability of the sacroiliac joint, the research is unclear on what amount of trunk and pelvic muscle activity is needed to provide sufficient stability to the sacroiliac joint during different tasks.
What are the signs and symptoms of sacroiliac joint dysfunction?
An athlete with sacroiliac joint dysfunction can present with a deep, diffuse, usually unilateral (i.e., to one side of the body) buttock pain that may be triggered after a change in activity level. To identify potential triggers, a thorough full history must be taken.
The onset (i.e., when signs and symptoms or the condition began), location and sensations of sacroiliac joint dysfunction can closely mimic that of lumbar spine (i.e., low back) issue. However, sacroiliac joint dysfunction is more likely to be reported below the level of L5 (i.e., the last lumbar spine vertebra) and possibly more directly over the sacroiliac joints, but rarely over the ischial tuberosity (i.e., extended and rounded bony parts of the pelvis that you sit on). Pain can also at times be felt bilateral (i.e., both sides of the body) and sometimes refer down the back and outside parts of the thigh.
Aggravating factors include any activities putting additional load through the sacroiliac joints like running, walking, sitting, lumbar spine movements and sporting tasks.
Sports chiropractic for sacroiliac joint dysfunction
The conservative management of a patient with suspected sacroiliac joint dysfunction must be multimodial (i.e., utilising many, diverse interventions and therapies) to reflect the psychosocial nature, as well as the complex anatomy, biomechanics and relationships that this area has with sourroiundg structures.
Many therapy techniques in and around the pelvis, lumbar spine and buttocks, such as soft tissue massage, joint mobilisations and manipulations have been advocated. However, it must be remembered, that the sacroiliac joint is highly congruent (i.e., the surfaces of the joints are connected very well, like a key in a lock) and well supported by immently strong ligaemtns and muscles, therefore therse techniques do not and cannot change or alter the sacroiliac joints physical position or affect is biomechanics in any way.
The effects of manual therapy around the sacroiliac joint is not fully understood; however, it is believed that it causes central and peripheral neuromodulation (i.e., the alteration of nerve activity through targeted delivery of a stimulus, such as manipulation) of the soft tissue and joint mechano- and nociceptors (i.e., specialised sensory receptors in tissues that respond to mechanical pressure or distortion and pain or potential tissue damage, respectively), which reduces sensations of stiffness and pain, rather than actual biomechanical or structural changes. Other more passive treatments include kinesio taping, pelvic belts and braces, which have been suggested to offer pain relief and assist weaker trunk mucles in the force closure of the pelvis.
Although initial treatments for a patient with sacroiliac joint dysfunction can focus on pain management, the ultimate goal is to restore the capacity of the sacroiliac joint and it surrounding tissues to withstand load, stress, shear and strain with a progressive strengthening and functional exercise rehabilitation program. Initially, the patient can begin with non weight-bearing exercises focusing on the posterior chain, the erector spinae, gluteal and hamstring muscles. These types of exercises may include bridges and their progressions combined with abdominal strengthening exercises. Progression of exercises should move towards exercises in weight-bearing positions, focusing on single plane movements, such as squats and deadlifts. More complex movements involving different planes of movement can be incorporated as the patient improves.
At Sydney Spine & Sports Centre (S3C) in Balmain, our sports chiropractors are highly trained to conservatively manage sacroiliac joint dysfunction using a wide range of evidence-based, safe and gentle techniques. We tailor treatment and rehabilitation programs to every patient. Make an online booking to visit the clinicians at our Inner West clinic today: www.s3c.com.au/book-now.
Please visit our website and blog page for more information on low back and pelvic pain:
- The Posterior Chain: Clinical Importance & Exercises
- Spinal Stiffness: Clinical Relevance & Management Strategies
- Lumbar Extension Exercises in Low Back Pain
- The Role of Gluteal Muscles in Low Back Pain
- How Chiropractors Treat Back Pain
- How Can Chiropractic Help After a Sports Injury?
- When to Worry About Back Pain
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