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SIJ Instability Stacey Vanorny and Adrienne Vickers

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Sacroiliac Joint Instability:

Sacroiliac Joint Instability Presented by: Stacey Vanorny and Adrienne Vickers June 9 th , 2012

General Description:

General Description SIJ moves but motions are small. Mean of 2.3 degrees (.7mm) of motion at the SIJ 1 Ligamentous support = sacrotuberous and sacrospinous principal stabilizers Muscular Support = Transverse abdominis , multifidus , and quadratus lumborum SIJ part synovial and part syndesmosis . More movement in females than males, support for highly specific tests and procedures to diagnosis SIJ instability is limited 2

General Description (cont):

General Description (cont) Cause: articular and/or myofascial factors 3 - articular instability- decrease ligamentous support results in increase translation and soft tisuue end feel of motion - myofascial instability-decrease muscle strength and patterning results in weakness of MMT

Signs:

Signs Hypertonicity of paraspinal muscles noted with observation and palpation AROM: Aberrant movement noted with forward be nding Hypermobile symphysis pubis Provocation Tests: SI gapping and compression, posterior gap/shear 4 Standing SI Mobility test ( Gillet test) – Good intra-examiner reliability 5 Therapist palpates bilateral PSIS, patient standing on 1 leg, flex contralateral hip, PSIS on nonweightbearing side should move inferior Palpable tenderness caudal to PSIS

Symptoms:

Symptoms Pain: Variable pain pattern – most common in buttocks and lower lumbar. Less than 50% to LE, distal to knee, and groin 6 Dull, aching, tight, pulling Difficulty with prolonged sitting requiring frequent readjustments Squatting, one-legged standing, and intercourse increase symptoms

Impact of Functioning:

Impact of Functioning Increased symptoms with prolonged sitting, trunk flexion and squatting activities Squatting increases SIJ instability ischial tuberosities separate, iliac crests roll in, sacrum nutates increased stress on SI ligaments Gait disturbances: loss of stability and muscular support for SIJ 3 displacement of COG exaggerated with SIJ instability compensation via weight transfer laterally over involved extremity to decrease vertical shear forces through the SIJ

Incidence:

Incidence Females 15-35yrs 7 Associated with pregnancy 8,9 Female pelvis: larger and wider pelvis with smaller, flatter and smoother joint surfaces - Hormonal changes cause increase ligamentous laxity - Increase strains from childbirth and intercourse - axis of support lies behind the hip joint and the COG and therefore results in posterior pelvic rotation with each step.

Diagnosis:

Diagnosis Combination of 3 or more positive provocation tests and no centralization or peripheralization of symptoms with repeated extension 10 -SI gapping, compression, posterior gap/shear , and posterior torsion via flexion of the hips Suspect SIJ problem: unilateral pain, not typical of nerve root quality, no lumbar articular s/s, no s/s in legs that can be attributed to lumbar spine 11 Radiograph have variable reliability and should be used in conjunction with a physical exam.

Prognosis:

Prognosis Most patients respond to non-operative treatment with use of lumbar stabilization and nerve blocks. Contraction of transverse abdominis helps stabilize SIJ 12 Corticosteroid injection in SIJ showed significant improvement in symptoms for a mean duration 5 months 13

Radiograph:

Radiograph Possibly the biggest reason for misdiagnosis or lack of diagnosis of SIJ dysfunction due to inability of radiological imaging to reliably discern the disorder MRI, CT, Bone Scan found to be inconsistent in diagnosing SIJ dysfunction A/P radiograph with alternating single-leg stance 14 Single-leg stance radiographs can be used to identify pathological amounts of motion at the SIJ Pathological motion can be considered to be greater than 5mm A/P radiograph of pelvis 15 Patient sustained SIJ instability from landing hard on mechanical bull separation of symphysis pubis, caudal displacement of sacrum, and widening of SIJs

One Leg Standing Radiograph A/P View:

One Leg Standing Radiograph A/P View

ABC'S:

ABC'S Alignment : Weight bearing on right leg shows translation at pubic symphysis. Slight caudal displacement of sacrum on ileum Bone density : Increased radiodensity and sclerosis apparent at SIJ. Increased radiodensity at the acetabular roof of the left hip Cartilage : Increased joint space left SIJ Soft tissue : Unremarkable

CT of Pelvis:

CT of Pelvis Right iliac positioned more posteriorly than left iliac. Increased joint space between the iliac and sacrum on the right indicating outflare on the right.

Biomechanical and Physical Impairments :

Biomechanical and Physical Impairments The radiograph shows increased translation of pubic symphysis; this could lead to gait disturbances due to increased shear force on the pelvis. Difficulty with squatting and pain due to the increased mobility at the joint therefore, decreasing stability at the SIJ. Difficulty with sitting for prolonged periods due to instability at the SIJ. Aberrant movements with forward bending Hypertonicy in paraspinals on side of instability Mutifidus atrophy secondary to back pain

Questions?:

Questions? Based on the radiographic image and knowledge of SIJ stabilizers what would be beneficial physical therapy interventions to improve findings? Looking at the CT image of the pelvis what other sacroiliac dysfunctions could present in a similar manner?

References:

References Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine. 1989;14(2):162-165. Walker JM. The sacroiliac joint: a critical review. Phys Ther . 1992;72(12):903-916. Lee D. Instability of sacroiliac joint and the consequences to gait. J Man Manip Ther . 1996;4(1):22-29. Laslett M, Williams M. The reliability of selected pain provocation test for SI pathology. Spine . 1994;19(11):1243-1249. Carmichael JP, inter and intra-examiner reliability of palpation for sacroiliac joint dysfunction. J Manipulative Physio Ther . 1987;10(4)164-71. Slipman CW, Jackson HB, Lipetz J et al. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil . 2000;81(3):334-38. Cyriax J. Diagnosis of soft tissue lesions. Textbook of Orthopaedic Medicine Vol. 1. 8th ed. London:Bailliere Tindall , 1982. Williams PL, Warwick R, Dyson M, Bannister LH. Gray’s Anatomy. 37 th ed. London:Churchhill Livingstone, 1989. Corrigan B, Maitland GD. Practical Orthopaedic Medicine . Oxford:Butterworth Heinemann, 1983. Laslett M, Young SB, Aprill CN, et al. Diagnosis painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provacation tests. Aust J Physiother . 2003;49:89-97. Grieve GP. Common Vertebral Joint Problems 2 nd ed. London:Churchhill Livingstone, 1988. Richardson CA, Snijders CJ, Hides JA, et al. The relationship between the transversus abdominus , sacroiliac joint mechanics, and low back pain. Spine. 2002;27(4):399-405. Bollow M, Braun J, Taupitz , et al. CT-guided intra- articular corticosteroid injection into the sacroiliac joints in patients with spondyloarthroplasty : indication and followup with contrast enhanced MRI. J Comput Assit Tomogr . 1996;20:512-21. Garras D, Carothers J, Olson S. Single leg stance radiographs to access pelvic instability: how much motion is normal. J Bone Joint Surg. 2008;90:2114-18. Conrad E. Imaging for Physical and Occupational Therapists. St. Augustine, FL: The University of St. Augustine for Health Sciences;2012.

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