Sacroiliac joint: mostly commonly affected joint due to its smaller articular surfaces. this slideshow briefs about its anatomy, biomechanics i.e. movements and axis, muscles, ligaments around it, types of dysfunction of SI joints, its special test and manual therapy management of the dysfunctions.

1. RADHIKA CHINTAMANIRADHIKA CHINTAMANI
Sacroiliac joint
Biomechanics,
SIJD and Manual
therapy for same
Sacroiliac joint
Biomechanics,
SIJD and Manual
therapy for same

2. CONTENTS
SI joint anatomy
SI joint biomechanics
Pathomechanics: SIJD types and etiology
Manual therapy for each SIJD with evidences

3. SI Joint anatomySI Joint anatomy
Formed by two bones; sacral complex and ilium.
Small joint with smaller articular surfaces.
Hybrid joint as the cartilage lying on sacral surface is hyaline and
that on ilial surface is fibrous.
This may be one important cause for early SI joint degeneration.

4. Muscles of SI joint
 Longissimus
 Multifidus
 Actions
 Pull sacral base
superiorly and
posteriorly through
dorsal ligaments.
Extensors of the
lumbar spine ( Trunk)

5. Contd..
 Piriformis
 Action
 Anterior tilt and rotate sacrum to opposite side
 Assisted by ipsilateral gluteus maximus
Contra lateral lattissimus dorsi & Gluteus maximus through LDF
 Action
 Nutation of sacrum and extension of LS junction
 Long head of biceps
 Action
 Backward tilt & rotate sacrum to same side.

6. Ligamentous complex of SI joint
Anterior Sacro-iliac
Ligament
Posterior Sacro-iliac
Ligament
Interosseous Sacro-
iliac Ligament
Sacrotuberous
Ligament
Sacrospinous
Ligament
Iliolumbar ligament

7. Function of Sacroiliac Ligaments
They also help to prevent the following:
Craniocaudal dislocation of sacrum
Anterior gapping
Posterior gapping
Hyperflexion
Hyperextension
Provides indirect stabilization to the SI joint.

8. SI Joint stabilization
Stabilization of the SIJ occurs through form and force
closure.
i. Form closure includes the passive stabilization
contributions of interlocking ridges and grooves on the
joint surfaces and ligamentous stabilization.
ii. Force closure is a term that corresponds to increased SIJ/
pelvis stiffness by isolated contraction of selected muscle
groups.
The SIj joint is protected from traumatic hear forces in three
ways:

9. Type of joint
 In joint structure classification :
- Synovial joint.
Subtype : Plane joint
 Joint function classification :
- Mixed diarthrotic / amphiarthrotic

10.  Role of SI Joint:
Stability –
• The effective transfer of load between the
trunk and the lower extremities during
both static and dynamic activities.
Flexibility –
• Walking
• Shock absorption during weight bearing

11. AXIS OF SI JOINTAXIS OF SI JOINT
TRANSVERSE AXES
Superior
Middle
Inferior
OBLIQUE AXES
Left
Right

12. Axis of motion
 Sacroiliac
– There are three major axes of motion:
•Horizontal = sacral flexion and extension;
•Vertical = sacral vertical shear; and
•Oblique = sacral torsion
 3 types of motion: innominate bone
 Symmetrical motion: is the movement of both innominate
as a unit in relation to sacrum: nutation and
counternutation
 Asymmetrical motion: antagonistic movement which
includes movement of symphysis pubis
 Lumbopelvic motion: movement of Lumbar spine over
pelvic complex consisting of (two ilium and sacrum).

13. When a 1,000 N force is applied to the sacrum,
rotational movements of the SI joint are
approximately, 1.6 degrees of axial rotation, 1 degree
of flexion or extension, and 1.1 degree of lateral
bending: H Sturesson et al. reported a mean rotation
of 2.5 degrees (0.8-3.9) and a mean translation of .7
mm (0.1-1.6 mm); Walheim and Selvik indicated the
pubic symphysis rotates 3 degrees and translates 2
degrees.
During single-legged stance, the symphyseal can
move vertically 2.6 mm and sagittally 1.3 mm on the
weight-bearing side.

14. SI JOINT MOVEMENTS: 1. Nutation
 Flexion of Sacrum over ilium
 “Sacral locking” (Close pack position)
 Articular surface glides in infero-posterior
direction (marked with thin red arrow)
 Bilateral Trunk flexion
 Bilateral hip flexion
 Supine lying to standing
 Exhalation
 Unilateral Hip extension
NUTATION

15. SI JOINT MOVEMENTS: 2.
COUNTER-NUTATION
 Extension of Sacrum over ilium
 “Sacral unlocking” (Loose pack
position)
 Bilateral Trunk extension
 Bilateral hip extension
 Standing to supine lying
 Inhalation
 Unilateral Hip flexion
COUNTERNUTATION

16. Etiology of SIJD

17. Types of SIJD’s
SacralSacral IlialIlial
Sacral nutation
- Unilateral
- Bilateral
Sacral nutation
- Unilateral
- Bilateral
Sacral
counternutation
Sacral
counternutation Up slipUp slip
Down slipDown slip
Outward rotationOutward rotation
Inward rotationInward rotation
Anterior tiltAnterior tilt
Posterior tiltPosterior tilt
Forward Sacral
torsion
Forward Sacral
torsion
Backward Sacral
Torsion
Backward Sacral
Torsion
PubisPubis
Inferior Pubic
shear
Inferior Pubic
shear
Superior Pubic
shear
Superior Pubic
shear

18. Sacrum tilts and not the ilium
B/L NUTATION B/L COUNTERNUTATIONB/L NUTATION B/L COUNTERNUTATION
Carefully observe the sacrum it is
taking a shape of “C”, you will find
“C” if u tend to do the movements
with your own hand in
counternutation.
Carefully observe the sacrum it is
taking a shape of opposite of “C”,
you will find the same if u tend to
do the movements with your own
hand in nutation.

19. NUTATION COUNTERNUTATION
Flexed sacrum Extended sacrum
Bilateral Unilateral Bilateral Unilateral
B/L flexed
sacrum
Inferior sacral shear B/L extended
sacrum
Superior sacral
shear
Pain worse with
forward bending,
walking,
standing,
climbing down
stairs
Pain usually in
sacral and gluteal
areas U/L,
Ipsilateral sciatica,
Gait problems, Pain
opposite side worse
with standing and
Relieved by sitting
Pain worse with
backward
bending, sit to
stand, walking,
climbing down
stairs
May be
associated with
anterior
innominate
dysfunction
Prefers to lie
prone
Usually traumatic,
land on one leg with
spine extended
lie supine Caused by
bending & twisting
followed by
forceful extension
with load.
Uncomfortable
sitting
Volleyball /
Basketball
----------- ------------
LS flexion limited LS extension ------------

20. 20
Unilateral Sacral NutationUnilateral Sacral Nutation
Unilateral anterior Sacral
Nutation:
ASIS Higher and PSIS Lower
on ispsilateral side
Unilateral posterior Sacral
Nutation:
ASIS Lower and PSIS Higher
on ispsilateral side

21. FORWARD SACRAL TORSIONFORWARD SACRAL TORSION
 Forward rotation around oblique
axis
 Prevalence 85%
 Occurs due to Imbalance between
piriformis & hip rotator muscles
and after postero-lateral disc.
 Symptoms
 Piriformis symptoms, gluteal pain
 Occasional sciatica

22.  Backward rotation around oblique
axis
 Lumbar side bending & rotation to
same side while fully flexed
 Locks with attempt to return to
upright position
 Symptoms:
 Heel burning, lateral knee pain,
inability to cross leg
 Back of leg numbness, can’t lie
prone
 Morning stiffness, pain with
walking
BACKWARD SACRAL TORSIONBACKWARD SACRAL TORSION

23. Ilial DysfunctionsIlial Dysfunctions

24.  Anterior Tilt
(11degrees= N)
Clinical signs
 ASIS is slightly
lower and facing
inferior
 Decrease in stride
length
 Presence of vertical
limp
 Often combines with
inflare of the pelvis
 Posterior Tilt (9
degree=N)
Clinical signs
-ASIS is slightly higher
and facing superiorly
-Decrease in stride
length
-Presence of stiff spin
and backward lurching
-Often combines with
outflare of the pelvis
TILT: articular asymmetry when the plane of the joint is excessively
Inferior or Superior.

25.  In flare:
Clinical signs
 weight bearing
through the lower limb
is painful.
 Subject walks with a
toeing in of the leg.
 positional fault of the
hip joint is present with
an apparent restriction
of lateral rotation.
 lateral rotation is also
painful.
 Out flare:
Clinical signs
-weight bearing through
the lower limb
increases the
symptoms.
-Subject walks with a
toeing out of the leg.
-positional fault of the
hip joint is present with
an apparent restriction
of medial rotation.
-medial rotation is
painful.
FLARE: articular asymmetry when the plane of the joint is
excessively anteromedial or posterolateral.

26.  Up Slip:
Clinical signs
 ASIS is higher compared to
contralateral ASIS
 weight bearing through the
lower limb is painful.
 Subject walks with knee
flexion of the unaffected
limb.
 Very rare; because it
requires pubic symphysis
rupture
 Often combines with
outflare and posterior ilial tilt
 Down Slip:
Clinical signs
-ASIS is lower compared to
contralateral ASIS
-weight bearing through the lower
limb is painful.
-Subject walks with knee flexion
of the affected limb.
-Very rare; because it requires
pubic symphysis rupture
-Often combines with inflare and
anterior ilial tilt
SLIP: one ilium is completely displaced superiorly with respect to
another

27. Piriformis SyndromePiriformis Syndrome
“Neuritis of branches of the
sciatic nerve caused by
pressure of an injured or
irritated piriformis muscle”
Symptoms: Radiating pain from the low back down over the sacrum into the
buttocks and hip region ,as well as down of posterior portion of the ,upper leg to
the popliteal region.
Causes: Short piriformis
muscle, overuse injury of
piriformis, continuous long
duration sacral sitting,
impingement of sciatic nerve
at the level of piriformis
muscle

28. Diagnosis
1. Special tests for sacral dysfunction
Type of Dysfunction Names of Special test
B/L Nutation Sacral Base pressure test
B/L Counternutation Sacral apex pressure test/Sacral
thrust test
U/L Nutation Sacral Base pressure test
Gillet’s test, Gaenslen’s test
U/L Counternutation Sacral Apex pressure test/Sacral
Thrust test
Gillet’s test, Gaenslen’s test
Forward sacral torsion Passive extension and Medial
rotation of ilium on sacrum
Backward sacral torsion Passive flexion and Lateral rotation
of ilium on sacrum

29. 2. Special tests for Ilial dysfunctions
Anterior pelvic tilt Ipsilateral Prone knee kinetic test
Duncan and allis test
Posterior pelvic tilt Torsion test
Outflare Squish test,
Inflare Squish test
Up slip Passive extension and Medial
rotation of ilium on sacrum
Passive flexion and Lateral rotation
of ilium on sacrum
Observatory finding
Down slip Observatory finding

30. 3. Special tests for Pelvic
dysfunctions
Inferior pubic shear Torsion stress test
Sacral rocking
Superior pubic shear Torsion stress test
Sacral rocking

31. Manual therapy
1. Joint mobilization
2. Muscle energy technique (MET)
3. Positional release technique (PRT)
4. Mobilization with movement (MWM)

32. Mobilization
Bilateral Poterior Nutated
Sacrum
Bilateral Anterior Nutated
Sacrum
Mobilization of base Mobilization of apex

33. Left Unilateral Anterior Sacral Nutation
Hold the sacral base
and mobilise the
affected side sacral
apex towards
counternutation
direction

34. Right Unilateral Posterior Sacral Nutation
Hold the sacrum stbale
and mobilise the ilium
by pushing it backwards

35. MET
 Bilateral Anterior
Nutated Sacrum
 Bilateral Posterior
Nutated Sacrum

36. Left on Left
Sacral Torsion
Right on Left
Sacral Torsion

37. Prone sacral PRT
MEDIAL SACRAL
PS1-corner of opp quad
PS5-sacral base opp
PS2 and PS3- downward
pressure to the apex of sacrum
in mid line
PS4-center of sacral base
Sacral foramen tender pts
Prone
Hip – abd 30 degree
slight flexion
Knee- ext rot

38. Anterolateral glide Posteromedial glide
Pushing the ilium anterolateral
while stabilising the sacrum.
Pulling the ilium posteromedial
while stabilising the sacrum.
Movement with Mobilisation

39. THANK YOU