Sacroiliac Pain: A Complex Puzzle
By Marc Heller, DC
I don't think we manage SI misalignment properly. First, we tell our patients they have an SI problem. I am not convinced this is accurate, and I will speak to that issue. Second, I think repetitive mobilization of the SI joints is not useful. I do think there are useful strategies that can help the chronically misaligned SI, which I will outline.
I tend to see a number of patients with chronic low back pain. Most of them have seen other chiropractors and/or PTs before they get to me. Often, the previous practitioner has told the patient they have an SI problem. What makes chiropractors and manual therapists think the SI is the problem? The patient will often point to the SI joint area as the place that hurts. In addition, in our exam, the sacroiliac landmarks often are misaligned.
Determining True SI Pain
In almost all lower back pain, one of the ilial landmarks, the ASIS or PSIS, has moved superior or inferior in the sagittal plane. Maybe you say the pelvis is out of line; maybe you call it a functional short; maybe you call it pelvic obliquity. You know these well: the common AS or PI ilium. This pattern tends to recur and is often seen, visit after visit. Whether we think the SI is hypomobile or hypermobile, the patient will present with an oblique, misaligned pelvis. If you are adjusting or mobilizing this pattern over and over, you are missing something. What else is wrong?
I think misalignment and pain over the SI area are not enough to make a diagnosis of sacroiliac pain. Pain felt in the SI area can come from many sources. Other joints that can refer pain to the SI area pain include the lumbar discs and the lower lumbar facets. The peripheral sensory nerves, which begin in the upper lumbar or lower thoracic spine, also can become irritated, referring pain to the SI. Muscle imbalances, whether looked at from a fascial restriction perspective or an inhibited core musculature perspective, certainly contribute to SI pain. Don't forget the abdominal contents, including the lower digestive tract, and the urogenital system. The pelvic girdle is a great adaptor. When something is stressed in the pelvis or lumbar spine, the SI will twist, misalign and adapt.
Three Diagnostic Tools
What leads us toward a more accurate diagnosis of true SI pain? Three tools are key. The first is provocation testing, stressing the SI ligaments. Research tells us this is one of the more reliable manual tests. If you stretch or stress the ligaments around the SI joint, and this reproduces the patient's pain, it points to the SI as a cause of the pain. Mike Reinold has a great piece on SI diagnosis, focusing on provocation testing, with some nice, simple videos.1
An SI or trochanter belt is another useful diagnostic tool. I keep a demonstration SI belt around. If I suspect the pain is coming from the SI, I will put the belt on the patient and instruct them to do a previously painful motion. If they hurt less (if the belt's support feels good to them), it is another sign the SI is probably unstable. (P.S.– Discogenic pain is also sometimes helped by an SI belt.)
Are the ligaments around the SI tender? This is another finding that correlates with true SI pain. Check the long dorsal SI ligaments, the iliolumbar ligaments, and both the origins and insertions of the sacrotuberous ligaments.
All three of these diagnostic procedures point toward SI hypermobility. Provocation testing stretches ligaments and makes the already sloppy SI move too far, thus reproducing the pain. An SI belt is an attempt to stabilize a joint that is moving too much. Tender ligaments usually implies they are irritated and overstretched.
The Hypermobile vs. Hypomobile SI: A Dilemma
If our main tool is the adjustment, we tend to think of all pain as being from something "out of adjustment." Another problem with our point of view: If our main tool is the adjustment, are we assuming every joint we see lacks mobility. Where are they hypermobile? Where are they fixated or hypomobile? Don't be fooled by the hypertonic muscles. The tight muscles are often compensating for the lack of joint stability, and lack of deeper core tone and function. An unstable, hypermobile sacroiliac is often surrounded by hypertonic buttock and lower back muscles.
The joint-by-joint approach reminds us the usual areas of hypomobility that affect the lower back include the hips and the thoracic spine. The usual areas of instability and hypermobility include the lower lumbar spine and the sacroiliacs.
Does the patient have a tendency toward ligamentous laxity? Are they systemically hypermobile? How far back can you easily bend their wrist, thumb and fingers? If they tend toward ligamentous laxity, their SI will "go out" more easily. These folks, the ones who are "double-jointed" or excessively mobile, tend to have more problems with ligaments, especially once they injure them. They look great doing yoga; they can do extreme positions. Once they suffer an injury, yoga is unlikely to be safe for them.
Has the patient had significant trauma? The trauma could have been recent or in the past. Either way, trauma to the pelvis or lower extremity can leave overstretched ligaments and/or may predispose the patient to pelvic problems.
In chronic lower back pain, the pelvis is most often both hypermobile and misaligned. In those cases, we are doing a disservice if we are repetitively adjusting that patient with high-velocity techniques. In the PT world, I see practitioners finding misalignment and repeatedly mobilizing the SI joint. Gentler mobilization may not be doing as much harm – but are you solving the problem?
Normalizing SI Motion
I know I may be challenging some of your deeply held beliefs. I know I am asking you to think a bit differently. I am not talking about the patient who needs a few adjustments every few years to normalize after throwing out their back. I am talking about the patient with ongoing or recurrent lower back pain and pelvic pain.
How do we resolve these chronic sacroiliacs? If the SI is unstable, what are you doing to create stability? The patient has to learn to move better; they need to rehab the weak and tight muscles. This can be done with all kinds of methods. Paying lip service to rehab is not enough. You need to get behind your exercise programs, encouraging and nagging your patients to actually do it. (This is also where I ask you, the practitioner: How fit are you? Do you exercise regularly? Do you walk the talk?)
What are the common muscle imbalances that affect the SI joint? I'll paraphrase Mark Comerford's model.2 Comerford points out that when the erector spinae is hypertonic, its attachment on the ilium pulls the ilium anterior. The multifidus is more medial and has some mild extensor action. When the multifidus is weak and not firing properly, the lumbosacral junction fails into flexion; consequently, the sacrum counternutates (sacral base moves posterior).
When the glutes are weak and not firing, they also contribute to the ilium tipping forward. When the hip flexors and TFL get tight, they pull the pelvis forward. (These imbalances are consistent with Janda's observations.) The net result: The sacroiliac tends toward the open pack position, ilium rotated anterior, and the sacral base moves posterior. This open pack position is inherently unstable and sloppy.
The answer has to be more than manipulation. Wake up the glutes and multifidi. Down-regulate the hypertonic erectors and hip flexors. The SI can re-establish the more stable, more closed, posteriorly rotated ilium positioning.
Other Conditions That Mimic / Cause SI Issues
Does your chronic lower back or buttock pain patient have a flexion-intolerant lower back?3 This can often express as both SI-area pain and SI misalignment. The patient can certainly have both SI and disc-related problems. The disc could be the main problem, creating a compensatory response in the SI.
Are the hips moving normally?4 If the hip lacks mobility or is functionally impinged, the SI will attempt to compensate for that. Hip issues are frequently underdiagnosed, as the hips often do not hurt despite malfunction.
What about upper lumbar and lower thoracic fixation?5 These dysfunctions create a triple whammy:
Mobilization of the SI joints
Let's finish with a brief description of pelvic / SI joint problems we need to correct. Whether the primary problem is the SI joint or not, we need to assess and correct sacroiliac issues in almost every lower back and lower extremity case.
If you accept my basic premise, you'll start to see SI dysfunction primarily as a hypermobility problem. If you can appreciate the joint-by-joint model, you have to ask: Where does that lead us? The logical conclusion: Repetitive side-posture adjusting to the often-hypermobile lower lumbar and SI joints is relatively contraindicated. The risk here is that you are contributing to further hypermobility and making a bad situation worse. We can create iatrogenic problems by performing repetitive standard chiropractic side-posture adjusting. Learn low-force, especially for the lower lumbar and the SI.
What gets missed? The SI is a complex joint. I have written several articles on the pelvic lesions I describe here.6 I have been strongly influenced by the osteopathic muscle energy technique's model of looking at the pelvis. I love the low-force techniques of muscle energy, and I appreciate the sophisticated way of looking at the multiple possible joint problems within the SI. That model differentiates iliac and sacral dysfunction.
Using muscle energy terminology to briefly describe these lesions, I know that in relation to the iliac side of the joint, it is useful to look beyond simple sagittal rotation patterns and evaluate for shears (upslips and downslips), and check for inflare and outflare patterns. I recognize the pubic symphysis is another significant pelvic joint that often needs to be assessed and realigned. When off, the left or right pubic tubercle will be quite tender.
The muscle energy model has a sophisticated way to address the sacral side of the joint. If you want to be a lower back expert, learn the muscle energy model, and know how to correct the sacrum as well as the ilium. Sacral-side dysfunction is both common and commonly missed.
I think we serve our patients best when we take a broad view of their problem. I find that when I correct the other problems I have described, the ilium corrects itself within the session. When the patient does the rehab and normalizes their musculature, their SI seems to stay better aligned.
Take a new look at the patients you have labeled as having SI dysfunction. It's a best-practice approach that involves us taking a bigger look. It is a question of putting together the most complete picture we can, taking into account multiple factors, and using both rehab and low-force manipulation.
References / Notes
Click here for more information about Marc Heller, DC.