Vladimir Djuric, MD
Although sacroiliac joint dysfunction (SIJD) may be present in as many as 40% of individuals who experience back, Buttock, and leg pain, it is frequently overlooked as a cause of these common symptoms. Of those clinicians who are familiar with SIJD, many feel it holds the distinction of being the single most common cause of chronic or recurrent low back pain. Despite its prevalence, SIJD is vastly under-recognized and often misdiagnosed. Even those practitioners who routinely treat it are frequently perplexed and frustrated by its complexity.
There are many different manners in which SIJD can manifest. In some cases the symptoms creep in gradually without an obvious cause. It is common during the second or third trimester of pregnancy and following lumbar fusion. Most frequently, trauma to the SIJ leads to injury of the SIJ ligaments. In any case, the resulting dysfunction disrupts the kinetic chain in which the SIJ is a key link. Subsequently, restoring normal function can be extremely challenging and in some cases virtually impossible.
Being a transitional structure, the SIJ can be thought of as either the bottom of the spine or the top of the leg; it really functions as both. The joint is not very large, especially considering the forces which cross it. What accounts for its stability are its irregular joint surfaces, wedge-like shape of the sacrum, and most importantly, the binding ligaments – the SIJ ligament complex. These ligaments, considered the strongest ligaments in the body, function like the cables of a suspension bridge. In order for the joint to function properly, each “cable” needs to provide a certain degree of tension and support; each plays a role in bridging the spine to the lower extremities, thus providing the stability necessary for fluid gait and normal body function. When the ligaments are stretched or torn, as a result of either a single trauma or repetitive impact loading, joint motion is altered. Joint dysfunction is the end result.
Even though the most powerful muscles in the body surround the SIJ, these muscles influence SI motion only indirectly. However, the effect the SIJ has on these muscles can be profound. The piriformis, iliopsoas, gluteals, quadratus lumborum, and hamstrings can all be affected to various degrees. With SIJD these muscles can become tense or spastic, ceasing to perform effectively. This further compromises gait and can lead to development of spinal dysfunction, hip bursitis and leg pain.
With SIJD most common complaint is pain in the buttock, hip, and/or low back. However, groin pain, more distant leg pain, burning, numbness, and tingling can also be experienced. In fact, SIJD is frequently mistaken for sciatica thought to be of lumbar origin. So convinced is the treating physician that there is a herniated disc responsible for the leg symptoms that 2 or 3 lumbar MRIs may be obtained, searching for that elusive disc Herniation.
As with the spraining of any joint, be it an ankle or SI, a sense of joint looseness or instability may be present. Excess motion in the form of abnormal shearing or rotation of either the sacrum or ilium can lead to joint subluxation and locking. The patient’s interpretation of such an event is most commonly “my hip/back/SI is out.” In addition to a sense that something is out of place, symptoms including increased pain, compromised movement, and an overall intolerance of certain positions, postures and activities may be present. SIJD can also be responsible for bowel and bladder irritability, sexual dysfunction, and a host of other symptoms.
In order to successfully treat SIJD, several factors need to be taken into consideration and properly addressed. These include altered joint mechanics, muscle dysfunction, and ligament incompetence. Manual therapy serves to re-educate the body. Various manipulation and mobilizations, some of which utilize the principle of indirect muscle effect on SIJ motion (muscle energy) help to realign the pelvis and spine. When possible, self-mobilization techniques are taught, enabling the patient to restore alignment on their own or with the help of a partner. Instruction in body mechanics and activity avoidance helps prevent recurrent subluxations.
It is important to restore proper muscle length, tone, strength and coordination. In order to address this myofascial component, the patient is instructed in specific exercises, including a regimented stretching program — an essential piece of the puzzle. Tight or spastic muscles inhibit progress and are many times responsible for perpetuating the dysfunction. Aquatherapy is useful means of initiating motion recovery and restoring movement patterns, particularly when excessive deconditioning or pain is an issue.
In cases where a leg length discrepancy (LLD) exists, heel lifts are utilized to reduce the degree of imbalance. In some cases, the leg length may be the cause of the dysfunction. More frequently, a previously asymptomatic leg length difference contributes to instability. Whereas prior to the injury, the ligaments were strong enough to compensate for the imbalance, after the injury this is no longer the case.
There are two types of LLD: true and functional. True LLD means that the bones of one leg from the heel to the hip joint are actually shorter than the other. With functional LLD, anatomic leg length is relatively equal. However, because of abnormal alignment in either the pelvis or lumbar spine, one side appears as if it were shorter than the other. The only accurate way to discriminate between the two is by obtaining a standing x-ray of the pelvis, then actually measuring hip heights on the x-ray film. A heel lift is sometimes necessary to correct for an excessive difference.
External supports in the form of a sacroiliac belt or possibly a firm girdle provide a degree of external stability during recovery. Some patients claim that even wearing a tight-fitting pair of jeans makes them more comfortable. These measures can be helpful in assisting the healing process, but are many times inadequate. Prolotherapy addresses the underlying cause of chronic SIJD: Ligament incompetence and joint hypermobility. Proliferant injections help in achieving the desired goal of strengthening and perhaps shortening the ligaments, thus decreasing the hypermobility and in turn improving overall joint dynamics.
The comprehensive approach described seems to have a synergistic effect on recovery. Such multifaceted care is especially necessary to treat the more complicated and chronic presentations of SIJD. With such cases, nutritional and hormonal effects on healing must not be overlooked. In circumstances where all other components of treatment have been addressed and properly executed, success may not be achieved specifically because an individual’s capacity to heal is compromised. For this reason, smoking cessation, nutritional support, and treatment of hormonal imbalances is essential.
My personal experience with SIJD has been both rewarding and frustrating. I have encountered situations where a seemingly simple and straightforward case turned out to be extremely complicated and challenging, necessitating a year or more of intensive treatment. Other times, what on the surface appeared to be quite complex was resolved with only minimal intervention. Admittedly, this is more the exception rather than the rule. But the lesson to be learned is that regardless of the chronicity, complexity and number of setbacks, improvement may be just around the corner. Our motto: never give up.