1. Sacroiliac Joint Dysfunction

2. Normal Anatomy Load transfer between spine and legs Basic platform with 3 large levers acting on it (spine, 2 legs) Nutation implies a tilting of the sacrum relative to the ilia, deeping of the lumbar lordosis whereas counternutation lessens the lordosis The upright position normally leads to nutation (closed packed position) Lots of controversy in the literature in the past as to how much (if any) movement occurs at the SIJ – Current thinking is 2-4 degrees

3. Normal Anatomy The anatomy of the joint surfaces contribute to a high coefficient of friction which enhances the stability of the joint against friction Sacrum is wider superiorly and anteriorly than inferiorly and posteriorly which wedges the sacrum in the ilia.

4. Male vs. Female SIJ Female – more uneven, less curved and more backward tilted, cavity shorter and more cylindrical. Curvature of joint surfaces are less pronounced in women allowing for more mobility – allowing for child birth SIJ ligaments loosen during pregnancy due to relaxin. Women with asymmetric laxity during pregnancy run biggest risk of PGP. Male – long and narrow, iliac crest higher, cavity longer and more conical. Lumbar isometric strength twice as great in males as females thus great loads transfers through SIJ (consistent with threefold greater occurrence of AS in males.)

5. Form Closure vs. Force Closure Shear is prevented by – form closure – Force closure Form closure – (i) the wedging of the sacrum into ilium – (ii) ridges and grooves of the joint surfaces – (iii) integrity of the binding ligaments Force closure – extensive attachments of ligaments and fascia to the muscles of the lower back and hips Form and force closure should be balanced. If a person lacks form closure, perhaps because genetics or anatomy, they will require more stability from muscles that assist in force closure Together force and form closure and neuromuscular control create a “self bracing” mechanism

6. Pathophysiology Pain arising from the structures in and around the sacroiliac joint of from the joint itself Long Posterior Sacroiliac Ligament and iliolumbar ligament most common source of pain – Offers resistance to sheering forces and loading Classically “Hypermobile” or “Hypomobile”

7. Mechanism Of Injury Traumatic – RTC – Falling/landing on buttocks or SIJ Insidious – Biomechanical changes – Leg length discrepancies – Muscle imbalances – Sitting for long periods Pregnancy – (20% of pregnant women will suffer with PGP) Systemic Inflammation – Spondyloarthropathies

8. Associated Pathologies Spondyloarthropathies

9. Subjective Pregnancy or recent child birth Recent trauma LBP not usually above L5 Ipsilateral buttock pain – May spread into leg and foot Pain on sustained load bearing Pain rolling in bed Pain getting in and out of cars Pain going up stairs Pain standing on 1 leg

10. Objective Pain with closure (extension, compression, jumping, single leg standing) Pain with “instability” in counter nutation (flexion, active straight leg raise) Tenderness palpation sacroiliac and ligaments Motion palpation tests unreliable Absence of centralisation with repeated movement

11. Special Tests Laslett et al (2005) (3/6 required) – Distraction Test – Thigh Thrust Test – Compression Test – Sacral Thrust Test – Gaenslens Test Thigh thrust and distraction should be performed first and if both are positive there is no need to continue with testing When all 6 provocation tests are negative, painful SIJ pathology may be ruled out Mens et al (2002) – Active Straight Leg Raise

12. Further Investigation MRI Radionuclide bone scanning CT Diagnostic Blocks All have variable results within the literature

13. General Management Difficult client group to worth with as diagnosis can often be difficult Pain post pregnancy can settle independently within 6 – 8 weeks Conservative management is focused on improving force closure and neuromuscular control Strengthen the muscles that attach into the SIJ via ligaments

14. Conservative - Management 1.Pain relief – Ice, NSAID’s, Pelvic Girdle Belts 2.Prepare Tissue – Massage, Foam Rolling 3.Restore Normal ROM – Soft Tissue ROM- Soft Tissue Techniques, Stretching – Joint ROM – Joint Mobilisation and Manipulation 4.Activate Muscles – Glutes, Hamstrings, Lats, external oblique's, erector spinae

15. Conservative - Management 5.Movement Impairments – Correct movement or biomechanical impairments – FMS, Biomechanics, Orthotics 6.Dynamic Stabilisation 7.Return to play specific

16. Plan B - Management Corticosteroid Injections Phenol Injections Radiofrequency Neurotomy Prolotherapy Surgical Debridement Fusion