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Achieve Relief / ABC PT Physical Therapy / 3502 S. 12th Street, Suite B, Tacoma, Washington / 253.564.2220 |
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The Sacroiliac Joint "Rediscovered" In the first part of the 20th century, sacroiliac joint syndrome was the most common diagnosis for low back pain, or lumbago. Before 1932, sacroiliac joint syndrome was a particularly popular diagnosis. It was actually called the "Era of sacroiliac Joint" because so many physicians felt that the sacroiliac joint was the cause of most back problems. Any pain in the low back, buttock or adjacent leg was usually referred to as sacroiliac joint syndrome. In 1932, the discovery of the herniated (or ruptured) disc led many physicians to assume that most pain in the back was the result of this new problem. Thus was born the "Dynasty of the Disc", and the sacroiliac joint was somewhat forgotten. In the late 1980s, many physicians "rediscovered" the sacroiliac joint as a possible source of back pain. Yet, even today sacroiliac joint pain is often overlooked as a cause of low back pain. Many physicians have not been trained to consider it when diagnosing back pain and many are still reluctant to believe a joint that has so little movement can cause back pain. Return to top The sacroiliac joint (sacroiliac joint) is one of two joints in your pelvis that connect the tailbone (the sacrum) and the large pelvic bone (the ilium). The sacroiliac joints connect your spine to the pelvis, and thus, the entire lower half of the skeleton. Like all true joints, there is articular cartilage on both sides of the sacroiliac joint surfaces. However, the sacroiliac joint is unlike any other joint in the body, because it is covered by two different kinds of cartilage. The articular surfaces have both hyaline (glassy, slick) and fibrocartilage (spongy) surfaces that rub against each other. No other joints have this feature! The joint also has many large ridges and depressions (ridges are bumps and depressions are dips in the surface) that fit together like pieces in a puzzle. Unlike most other joints, the sacroiliac joint is not designed for much motion. In fact, it is common for the sacroiliac joint to become stiff and actually "lock" as we age. This might explain why manipulation and mobilization techniques have proven to be useful in physical therapy for sacroiliac joint syndrome. Mobilization is a technique where a joint is mobilized or loosened by certain exercises and stretches that the therapist can perform or teach you to perform. The sacroiliac joint usually only moves about two to four millimeters during weight bearing and forward flexion. This small amount of motion occurring in the joint is described as a "gliding" type of motion. The motion is quite different than the hinge motion of the knee or the ball and socket motion of the hip. The sacroiliac joint is a "viscoelastic joint", meaning that its major movement comes from giving or stretching. The sacroiliac joint's main function appears to be providing shock absorption for the spine through stretching in various directions. The sacroiliac joint may also provide a "self-locking" mechanism that helps you to walk. The joint locks on one side as weight is transferred from one leg to the other. Due to its small amount of movement and its complexity, finding out about the sacroiliac joint's motion is very difficult during a physical examination. This is one of the big problems in diagnosing sacroiliac joint problems. Return to top
In some patients, pain occurs because of an abnormality of the sacrum bone itself. The sacrum bone is actually a very specialized set of vertebrae (the bones that make up the spine). Before birth, when your body is undergoing development in the womb, several vertebra fuse together to form the sacrum. However, in some people, the bones that make up the sacrum never fuse together. In these cases, two or more of the vertebra that should fuse together remain separated. This creates an odd situation where the sacroiliac joint is somewhat malformed, and a false joint occurs. This is sometimes called a "transitional syndrome". This problem can be seen on X-rays. People who have this syndrome seem to have more problems with their sacroiliac joints, as well as back pain that appears to come from that area. Women are at risk for developing sacroiliac joint problems later in life due to childbirth. During pregnancy, female hormones are released that allow the connective tissues in the body to relax. The relaxation is necessary so that during delivery, the female pelvis can stretch enough to allow birth. This stretching results in changes to the sacroiliac joints, making them "hypermobile" - extra or overly mobile. Over a period of years, these changes can eventually lead to wear-and-tear arthritis. As would be expected, the more pregnancies a woman has, the higher her chances of sacroiliac joint problems. During pregnancy, the sacroiliac joints can cause discomfort both from the effects of the hormones that loosen the joints, and from the stress of carrying a growing baby in the pelvis. Many other problems can lead to degenerative arthritis of the sacroiliac joints. It is often hard to determine exactly what caused the wear and tear to the joint. Return to top
Sacroiliac joint problems have numerous symptoms, the most common include:
In most cases, there is a confusing pattern of back and pelvic pain that mimic each other, making diagnosis of sacroiliac joint problems very difficult. Return to top
The diagnosis usually begins with a history of the problem.
Following this, your provider will perform a physical examination to try to find the source of your back pain. Many of the tests will be trying to determine whether the problem is coming from the spine or from the sacroiliac joint. Your clinical exam may include the following orthopedic tests used to determine if the sacroiliac joint is involved. Pain during these tests is generally an indicator that the sacroiliac joint is indeed a problem.
X-rays may also be recommended by your provider to determine if there are abnormalities of the joint that can be seen on X-rays. A CAT scan can sometimes show more detail about the joint surfaces and the surrounding bone. If the X-rays suggest something may be affecting the sacroiliac joint, your provider may recommend a CAT scan to get a better look. A bone scan can be useful in determining if the joint is inflamed. An inflamed sacroiliac joint usually shows up as a hot spot on a bone scan of the pelvis. Your provider may also recommend that you undergo a fluoroscopic injection into the joint. During this test, a local anesthetic is injected into the joint. The doctor uses the fluoroscope to make sure the needle is actually in the joint before injecting the medication. The sacroiliac joint is located fairly deep in the upper buttock and is covered by thick muscle. It is difficult to put a needle into the joint without some guidance. A fluoroscope is a special TV camera that uses X-rays to allow the doctor to see on the screen the exact placement of the needle, making sure it is positioned accurately. Once the doctor is sure that the needle is in the right place, the anesthetic is injected to numb the joint. If the pain goes away, your provider can be relatively sure that the problem is coming from the sacroiliac joint and not somewhere else in the spine. The doctor may also add a dose of cortisone to the injection to help ease your pain. Cortisone is a powerful anti-inflammatory medication that calms the arthritis inside the joint and reduces your pain. The effect is usually temporary, but may last up to several months. Return to top
If your provider feels that your back pain may be a result of sacroiliac joint syndrome, you will likely be presented with two completely different treatment options. These two options for non-surgical treatment may appear to be exact opposites - manipulation or stabilization. Why would the two treatments for one joint be so different? No one really knows what causes the pain from an sacroiliac joint that is not suffering from severe degenerative arthritis. In some cases, it appears that the joint is "too stiff" or "locked" and needs to be more mobile to function correctly. In these cases, the pain seems to respond to mobilization of the joint. In other cases, especially when there are definite arthritic changes noticeable on X-rays, reducing the mobility of the joint may decrease the pain. Treatment is understandably varied and the results of treatment have been difficult to assess because of the complexities of the sacroiliac joint. The appropriate approach is still somewhat unclear to many providers. Both the mobilization approach and the stabilization approach to treatment involve physical therapy. Mobilization of the joint may include exercises and manipulation by the therapist. This type of therapy is directed to loosening up the joint ligaments, allowing the joint to move in a normal fashion. Stabilization of the joint may include muscle strengthening and pelvic stabilization exercises to reduce the movement in a joint that appears to be too loose. Stabilization can also be accomplished through use of a specific brace called the sacroiliac belt. The belt wraps around the hips to squeeze the sacroiliac joints together. This supports and stabilizes the pelvis and sacroiliac joints. Return to top |
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For questions and
general information e-mail us at:
relief@abcphysicaltherapy.com |
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One
of the most common causes of problems at the sacroiliac joint is an
injury. The injury can come from a direct fall on the buttocks, a motor
vehicle accident, or even a blow to the side of your pelvis. The force
from these injuries can strain the ligaments around the joint. Ligaments
are the tough bands of connective tissue that hold joints together.
Tearing of these ligaments can lead to too much motion in the joint. The
excessive motion can eventually lead to wear and tear of the joint and
pain from degenerative arthritis. Injuries can also cause direct injury
of the articular cartilage lining the joint. This too, over time will
lead to degenerative arthritis in the joint.