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Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 1
Slide 1
ASSESSMENT & TREATMENT OF MECHANICAL SACROILIAC DYSFUNCTION
Slide 2
WEBINAR OUTLINE
1. A brief review of challenges of assessing and treating the SIJ.
2. A visual guide to hypothetical SIJ motion.
3. A visual guide to assessing and treating the SIJ.
4. Non mechanical causes of SIJ dysfunction and suggested
treatment approaches.
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 2
Slide 3
INTRO
- First introduction to sacroiliac dysfunction.
- Research proves SIJ motion and that it
can contribute to low back pain.
- Clinical utility testing inconclusive (palp vs pain).
- I don’t find pain provocation tests that helpful.
Slide 4
INTRO
- Innominate dysfunction can create
painful hypermobility in the SIJ.
- Palpation for anomalies also is unreliable
and can yield false positives.
- Clustering of tests most helpful.
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 3
Slide 5
HYPOTHETICAL SIJ MOTION
Figure 1. Transverse sacral axis. From (1) Figure 2. Nutation and Counternutation from (1)
Slide 6
HYPOTHETICAL SIJ MOTION
Figure 3. Flexion from (2) Figure 4. Extension from (2)
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 4
Slide 7
HYPOTHETICAL SIJ MOTION
Figure 6. Sacral AxisFigure 5. Left Quadrant or Sidebending. From (2)
Slide 8
Figure 7. Weight distribution from (3)
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 5
Slide 9
ILIOSACRAL MOTION
The iliosacral joints move from a position
of anterior rotation and inflare at heelstrike
to a position of posterior rotation and
outflare at heel off.
Slide 10
SACROILIAC MOTION
During the walking cycle the sacrum moves from
a position of left rotation to a left torsion on a left
oblique axis as the right leg heelstrikes. By push
off of the right foot, the sacrum has moved to a
right torsion on a right oblique axis.
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 6
Slide 11
KEY CONCEPTS
• Structural positional dysfunction
• Adaptive positional dysfunction
• Traumatic positional dysfunction
Slide 12
KEY CONCEPTSImagine a line drawn
through both ears. Are they
parallel with lines drawn
through the tips both a/c
joints and both iliac crests ?
INDIRECT METHOD LLDVisually compare the heights of the iliac crests. The lower side may represent a short leg.
The indirect method using lifts had superior validity, interobserverreliability, and specificity over the direct supine method using tape measure. Both clinical methods underestimated LLD compared with radiograph 4.
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 7
Slide 13
KEY CONCEPTS
LEG LENGTH INEQUALITY (LLI)
Anatomic LLI common (90%) with average
5.2mm and 15% with 10mm or more.
Right leg shorter 50-75%5
Slide 14
KEY CONCEPTS
•
FUNCTIONAL LLD 6
A: 60% have a C-type scoliosis,
a posterior innominate rotation
on the side of the elevated
innominate and an atlas
elevated on the side opposite to
the elevated innominate.
B: 40% have a S-type scoliosis
with an anterior innominate
rotation on the side of the
elevated innominate and an
atlas elevated on the same side
as the elevated innominate
Image from 6
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 8
Slide 15
1° - ILIOSACRAL TESTPELVIC SPRING TEST
The patient lies supine and lifts their
pelvis off the bed before repositioning the
pelvis in neutral.
The operator stands to the side and
places the palm of each hand over
the lateral pelvic rim and ASIS.
The operator introduces a gentle glide of
the ilium on the sacrum at a 45º angle.
The positive side is the side that feels
most restricted.
+/- STANDING FWD FLEXION OR GILLET TEST
Slide 16
2°- ILIOSACRAL TEST
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 9
Slide 17
2°- ILIOSACRAL TESTPELVIC LANDMARKS
The patient lies supine and the operator
lightly palpates both ASIS for alignment in
the superior /inferior & medial/lateral
directions.
The side of dysfunction is the side with the
most restricted pelvic spring test.
1. Superior ASIS = posterior rotated
innominate
2. Inferior ASIS = anterior rotated
innominate
3. Lateral ASIS = outflared innominate
4. Medial ASIS = inflared innominate
1 2
3 4Images from 1
Slide 18
1°- SACROILIAC TESTSACRAL SPRING TEST
The patient lies prone while the operator places the heels of their hands over the sacral base. The operator applies a gentle ventral force to the sacral base feeling for ease of sacral nutation. Lack of motion is considered a positive test.
The operator can also reverse the hand positions to apply force at the sacral apex and test for ease of counternutation.
+/- Recoil
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 10
Slide 19
2°- SACROILIAC TESTSACRAL POSITION
1. Depth of the sacral sulcii
The operator places their thumbs on the
patients PSIS bilaterally and curls their
thumbs medially and caudally to compare
the depth of the sacral sulcus bilaterally.
Check also for sulcus tenderness.
2. Level of the inferior lateral angles
The operator places the pads of both
thumbs 15-20mm lateral to the sacral
hiatus and compares the level bilaterally
on the coronal plane. The operator then
rolls their thumbs under the sacral ILA’s
to compare the level bilaterally on the
horizontal plane.
Slide 20
SACRAL JCS POINTS
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 11
Slide 21
JCS TECHNIQUE1. Locate the tender point.
2. Find position of comfort or mobile point.
3. Monitor point response but take pressure off.
4. Hold 90 seconds.
5. Return to neutral slowly.
6. Recheck tender point – 70% improved.
Slide 22
SACROILIAC JOINT L PS1 POSTERIOR SACROILIAC 1
DX: SS deeper on R and ILA more posterior
on left. +ve Spring Test
PD = LST/ROA
Tender point: 1.5cm medial to PSIS
RX: Patient Prone.
Apply a ventral pressure with the heel of the
hand on the opposite corner of the sacrum
(right sacral apex). Produces a left backward
sacral torsion on an oblique axis.
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 12
Slide 23
SACROILIAC JOINT L PS5 POSTERIOR SACROILIAC 5
DX: SS deeper on R and ILA more posterior on
left. –ve Spring test
PD = LST/LOA
Tender point: 1cm medial and 1cm superior
from left ILA.
RX: Patient Prone. Apply a ventral pressure on
the opposite corner of the sacrum (right sacral
base) to produce a forward sacral torsion on an
oblique axis.
Slide 24
NON MECHANICAL SIJ DYSFUNCTION
Dx - Sphenobasilar dysfunction
Rx – Counterstrain or Craniosacral therapy
Dx – Cecal, Sigmoid or Uterus dysfunction
Rx – Counterstrain or Visceral manipulation
Dx – Sacral epidural vein dysfunction
Rx - Counterstrain
Assessment & Treatment of mechanical SIJ dysfunction ©MTI 2020 Page | 13
Slide 25
For references, a copy of the slide notes and
information about the 2 day Assessment &
Treatment Intro course please got to:
manualtherapyinstitute.com/mma
References
1. “Glossary of Osteopathic Terminology,” 2011. https://www.aacom.org/docs/default-
source/insideome/got2011ed.pdf
2. Lee D, The Pelvic Girdle: an approach to the examination and treatment of the lumbo-pelvic-hip region., 2nd ed.,
London: Churchill Livingstone, 1999.
3. Richter P & Hebgen E, in Trigger Points and Muscle Chains in Osteopathy, Thieme, 2009
4. Badii M et al. "Comparison of Lifts Versus Tape Measure in Determining Leg Length Discrepancy." The Journal of rheumatology 41.8: 1689-1694. 2014.
5. Knutson G, "Anatomic and functional leg-length inequality: A review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance," Chiropr Osteopat, vol. 13, no. 11, 2005. 6. Timgren J & Soinila S, "Reversible Pelvic Asymmetry: An Overlooked Syndrome Manifesting as Scoliosis,Apparent Leg-Length Difference, and Neurologic Symptoms," Journal of Manipulative and Physiological Therapeutics, vol. 29, no. 7, pp. 561-565, 2006.