2. z FUNCTIONAL
ANATOMY
Synovial joint between sacrum and ilium
Irregular elevations and depressions fit into one another.
Sacral surface is concave and iliac is convex
Primarily design for stability
Changes with age : in child hood smooth and flat, gliding motions possible in all direction.
after puberty configuration change and only flexion and extension is possible.in elderly
osseous union may occur and ankylosed. mobility is lower in men than in women.
Ligaments: posterior ligaments prevent forward tendency of sacrum in WB. Anterior
ligaments slight thickening of capsule, restrict distraction. Sacrotuberous and sacrospinous
restrict flexion.
6. zSacroiliac joint
syndrome
Sacroiliac joint syndrome is a significant source of pain in 15% to 30% of mechanical
low back pain sufferers.
Mechanical dysfunction of the sacroiliac joint results in more pain and decreased
mobility.
This causes an inflammation of the joint making it possible to disrupt. Degenerative
changes need to be considered as well.
Traumatic incidents such as motor vehicle accidents, falls landing on the buttocks, and
cumulative injuries, such as lifting and running, are the most common causes.
It occurs more frequently in older people, but there is too little research done to
substantiate this conclusion.
Sacroiliac Joint Syndrome is a condition that is difficult to diagnose and is often
overlooked by physicians and physiotherapists
7. zClinical signs of sacroiliac dysfunction:
Pain and local tenderness, with increased pain on position changes such as
ascending or descending stairs or slopes or rising from sitting or lying to
standing.
Pain may also increase with prolonged postures in standing or sitting.
It may also refer to the groin, over the greater trochanter, down the back of the
thigh to the knee, and occasionally down the lateral or posterior calf to the
ankle, foot, and toes.
Pain may also be referred to the lower abdomen;
8. zHypomobility
lesions
usually occur in young people and may be associated with movements that place a rotational stress on
the SIJ, such as ballet or golfing.
It can also occur insidiously and may be associated with certain structural faults such as asymmetric
development of the pelvis or unequal leg length.
Pain may result from sustained contraction of the muscle overlying the joint, or from a muscle-pain
disorder.
This hypertonicity may accompany dysfunction of the SIJ or the lumbar spine.
In a leg-length discrepancy, the pelvis must drop a distance equal to the amount of the discrepancy with
every step.
9. zHypomobility
lesions
More compression forces to the shorter side more shear forces to the opposite sacroiliac
side.
The tilted position of the sacrum results in alteration at the hip, lumbar spine and knee. OA
of hip on longer side
With respect to the lumbar spine, there is side bending motion away from the short side,
with compressive forces placed on the concave side and tensile forces on the convex side.
Osteophytes may develop on the lumbar vertebrae on the side of the concavity produced by
leg-length inequality.
Compensatory anterior rotation of the innominate is associated with a short lower limb,
compensatory posterior rotation with a long lower limb.
10. zHypermobility
lesions
occur in one of two situations
FIRST
secondary to instability of the symphysis pubis, which occurs predominantly in
athletes.
This condition may be complicated by a mechanical lesion of the lumbar spine
or one or both SlJ.
SECOND
occurs in young females, usually during or soon after pregnancy
Ligaments may remain lax for 6 to 12 weeks after delivery or longer.
Occasionally the symphysis may become a truly mobile joint, with pelvic
instability as a result.
11. zHypermobility
lesions
Movement abnormalities of the sacroiliac, the pubic joints, and the lumbar spine
may be a cause of persistent postpartum pain.
Under the influence of the hormone relaxin, there is a physiological pelvic girdle
relaxation that may produce symptoms
Physiological pelvic girdle relaxation normal ligament relaxation during
pregnancy.
symptom-giving pelvic girdle relaxation that which results in pain or pelvic
instability.
12. zDegenerative
changes
common with advancing age
associated with
chronic neurological conditions such as paraplegia and hemiplegia
chronic structural abnormalities such as;
leg-length discrepancies
scoliosis
pelvic asymmetries
hip disease (osteoarthritis)
Degenerative changes first involve the iliac surface, where the cartilage is thinner than on the sacral
surface.
The cartilage changes are similar to those in peripheral joints with, ultimately, a fibrous ankylosis of
the joint cavity.
condensation of bone on the iliac side of the SIJ.
13. z
Osteitis
Condensans Ilii
a bony reaction to unequal stress in this joint.
usually bilateral
occurs mostly in young adults, more commonly in postpartum
Disappears with menopause
mimics inflammatory disease
14. z
INFLAMMATORY DISEASE AND INFECTIONS
Other conditions to be considered in the differential diagnosis of sacroiliac dysfunction
include infections and metabolic conditions.
Infections usually involve only one SIJ and may be a staphylococcal or tubercular infection,
a sexually acquired infection, or one related to intravenous drug abuse, among many other
sources.
Inflammatory sacroiliitis conditions are either infectious or seronegative
spondyloarthropathies.
Of the latter, the major ones are ankylosing spondylitis, Reiter’s syndrome, and psoriasis.
Ankylosing spondylitis is usually bilateral and symmetric; involvement of the SIJs is the
hallmark.
20. zMuscles tests
Sagittal plane:
Ant or post rotation dysfunction: in unilateral post innominate rot the G-maximus,
hamstrings and adductor magnus become short and tight while hip flexors, sartorius and
other adductors become stretched and weak.
If unilateral anterior rotation dysfunction exists, the hip flexors, adductors, and tensor
fasciae latae become tight on that side while the hamstrings, glutei, and abdominals
become stretched and weak.
Anterior or posterior pelvic tilt:????
Frontal plane:
If LLD present then on the long side the quadratus lumborum, iliocostalis lumborum,
iliopsoas, obliques, and rectus abdominis become tight, while the hamstrings, adductors,
rectus femoris, sartorius, and tensor fasciae latae become stretched and weak.
The opposite muscle imbalances occur on the side of the shorter leg.
Subjects with leg-length differences are generally weaker on the short side
21. zManagement
1) sacral counternutation dysfunction: caused by postural flat back, flexed sitting or standing
postures and coccygeal muscle spasm.
Signs: lumber spine hyperflex, shallow sulci, deep inferior lat angles, less prominent PSIS,
sacral flexion restriction, and L5-S1 restriction in extension.
Sacral nutation technique:
P –prone with a pillow under abdomen and legs ext rot.
O –stands on involved side
M –hand contact the sacral base, glide the base ventrally directing the sacrum into nutation.
Management include postural reeducation, to avoid flex sitting and standing, activities to
promote lumber extension mobility, prone press up.
22. zManagement
2) sacral nutation dysfunction: caused by inc in lumbosacral angle because poor abdominal
tone, lumber spine hyper extension, and weak gluteus medius and max .
Signs : deep sacral sulci, shallow inferolateral angles, increase psoas tone, sacral flexion
hypermobility, and sacral extension restriction, tender and tight TFL.
Sacral counternutation technique:
P –prone with legs int rot.
O –to one side facing head.
M –with thenar apply posteroanterior force on the apex, cause extension at sacrum.
Management include promotion of lumber flexion activities and postures, soft tissue mob
and stretch of tight structures, strengthening of gluteus max and med and abdominals.
23. zManagement
Posterior innominate rotation dysfunction:
Signs: on the involved side include an inferior and posterior PSIS, a superior ASIS, a positive standing
flexion test.
Forward Rotation. Prone position
P—Prone.
O—Places the cranial hand directly over the patient’s ilium. The opposite hand reaches around to
grasp the anterior aspect of the distal thigh of the near leg.
M—Movement is produced by simultaneously pressing on the proximal ilium with the heel of the hand
and lifting the leg, thus rotating the proximal ilium forward (anteriorly)
Forward Rotation. Supine position
P—Supine, with the leg on the side to be mobilized extended over the edge of the table
O—Stands opposite of the side to be mobilized. The patient or operator flexes and stabilizes the
opposite leg.
M—Place the caudal hand over the thigh and use it to push the hip into further extension; the cephalic
hand can be applied to the patient’s PSIS, pushing upward to increase the forward rotation of the
innominate on the sacrum.
25. zManagement
Anterior innominate dysfunction:
Signs: on the involved side include a superior and anterior PSIS, an inferior ASIS, a
positive flexion test.
Backward Rotation:
P—Lying on the side opposite the joint to be moved.
O—Flexes the patient’s hip and knee. The operator’s more cranial hand contacts the
patient’s anterosuperior iliac spine, and the opposite hand contacts the ischial tuberosity.
M—Movement is produced by a force-couple, pushing the anterosuperior iliac spine
backward and the ischial tuberosity forward. Further pressure is placed against the
patient’s leg with the operator’s abdomen.
26. zManagement
Innominate Upslip: An Upslip is a superior subluxation of the innominate on the sacrum at the SIJ.
Possible muscle findings include quadratus lumborum spasm and tight hip.
Causes: include jumping or falling suddenly on an extended leg or, more commonly, from a fall on the
ischial tuberosity.
Signs: on the involved side include superior positioning of the ASIS, PSIS, iliac crest, pubic tubercle,
and ischial tuberosity. Inferior glide of the ilium is restricted.
Inferior glide:
P—Prone
O—Stands to the involved side at the head
M—The outer hand contacts the superior aspect of the iliac crest and applies an inferior and slightly
medial force in the plane of the joint.
Distraction:
