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Sacral dysfunction
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Sacral dysfunction - January 21, 2004 5:11:00 AM
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PTBuck
Posts: 3
Joined: January 20, 2004
From: Savannah, GA, USA
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To all helpful PTs:
I have been seeing a 28y/o female who has presented with SI joint pain for past 3 months since her pregnancy. She reports pain at worst is 10/10, but only occassionally. I have looked/palpated several times, used several special tests, but still feel without any good source of where to go next. I appears as if the sacrum is extended on the left and deep on the right. She reports relief with PT pressure on the left. I have tried several METs to correct, without sucess. I have looked into a SI brace for some relief, but I am unsure about how well these devices work. Any advice, or further resources would be much appreciated. It seems to me like the pelvis and sacrum are the least understood(easiest to confuse) areas of the body. Thanks again. I'm happy to find a good PT forum...
Greg
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Re: Sacral dysfunction - January 21, 2004 8:02:00 AM
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Shill
Posts: 1092
Joined: February 13, 2003
From: Madison WI USA
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Greg,
A couple o' questions first. What are the "occasions" when her back hurts? (With as much specificity as you can provide.) if you are unsure of if an SI belt will work, just get one and try it. Strap her in, crank it tight, and you will find an answer. If it helps, it is an awfully cheap solution. I believe, though someone can correct me if Im wrong, that the relaxin hormone will still be around if breastfeeding is still taking place, thus a belt may be warranted for a while, if the hypermobile ligaments have anything to do with her pain.
However,
Most of the quality research explains why the SI is so misunderstood. Unreliable evaluation means. All based on palpation, and analysis of miniscule movement. Too much margin for error. The SI gurus will argue, but the data is there. Perhaps they are better than those studied, but, I doubt it. I used to entertain myself by attempting to treat the SI as a pathological entity contributing to lumbosacral pain, but I found it futile. I am a self-proclaimed "lumbar head". This may frighten some of my colleagues, but I just dont think the SI joint deserves a whole lot of recognition, as most efforts to identify pathologies and treatment strategies are of poor structural basis. I have seen very few radiographs of the purported SI pathologies. Lots of Drawings, but no actual radiographs. I find this rather interesting. There are plenty of radiographs demonstrating pathological conditions in the lumbar spine.
I am able to use repeated movements approaches to help people with lumbar/sacral pain get better. I have enough evidence to use these techniques, and it makes a whole lot of sense to me, whereas SI treatment typically does not.
Keep in mind, these are simply the opinions of a 10 year veteran in the orthopedic PT realm. Others will have more to add. I imagine there will be a few statements against my advice to spend your time looking at the L-spine instead.
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Re: Sacral dysfunction - January 21, 2004 12:47:00 PM
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mcap56
Posts: 617
Joined: October 26, 2002
From: New York, NY
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The studies on SIJ evaluation are indeed poor. And, I also would agree that the SIJ is very overexamined by a lot of the ortho types out there. The reliability and validity of the evaluation systems are not acceptable.
However, some quality injection studies do implicate the SIJ as a pain generator in a significant percentage of patients (can be 15% or higher). And Laslett has developed a system with good reliability and validity as well as good sensitivity and specificity.
The SIJ barely moves at all. Think of it as a load bearing joint with tiny, unpredicatable movements......it may make more sense that way. Trying to palpate to find positional faults may be a waste of time.
AS for treatment options, you still have some. The SI belt gets worn all day, every day, for about 3 weeks. To test it - use it or some other belt you have in the clinic and see if the patient gets releif. If they do, you can give it a try (as posted above).
You should put her through the segmental stabilization program by Richardson, et al. The TA helps with force closure of the SIJ and the mutlifidi actually cross the joint. It should be the mainstay of your treatment.
Best of luck!!!!
mcap
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Re: Sacral dysfunction - January 22, 2004 3:23:00 AM
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gilbert thomson
Posts: 24
Joined: November 17, 2003
From: Elka Park, NY USA
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Yes, research shows that the SIJ palpation exams are unreliable. But...somehow my personal experience has differed from some of the studies I've read.
I don't see a great number of ortho patients in my practice, but a large percentage of my patients with LBP seem to have SIJ involvement (~25%), often with large, obvious asymmetries seen in the supine to sit test (like: 2 cm leg length difference in one of the positions). I have personally found the simple METs to correct innominate rotation very effective in both reducing the asymmetry and relieving the Pt's pain. But, as I said, this is only my personal experience, and it doesn't seem to agree with the most recent "evidence-based" trends.
My most interesting SIJ patient had a large asymmetry post-partum, and symptoms of sciatica with true neurological signs (incl. weakness) in the involved LE. After using the METs to help move the SIJ into better alignment, the sciatic symptoms and signs disappeared.(BTW the patient had a negative CT scan) Very atypical presentation, but I guess the SIJ is anatomically very close to the sacral plexus and can sometimes affect it.
Good luck - Gilbert
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Re: Sacral dysfunction - January 22, 2004 4:35:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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As Gilbert and mcap indicate, the palpation results can be quite unreliable. One may often "feel" what he/she is expecting, or wants to feel during the exam, subconsciously.
Often those who swear by their palpation skills, especially when noting "ILA more caudal, sacrotuberous ligament more taut and posterior, sacral sulcus deeper" on a 350 woman usually can't even tell which side of a quarter they are palpating when I stick it in their hand!
As Shill indicates, there may be a hormonal issue, as she is not that far out post-partum, and the SI belt is a very easy thing to try. If no belt in stock, just strap around her waist with athletic tape, over the clothes, and let her spend the day with it on.
There are some MET techniques that I personally use for these patients and have good luck at times, even when others have failed. Perhaps a different positioning, instruction, I don't know. Never hurts to try
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: Sacral dysfunction - January 22, 2004 8:48:00 AM
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coloradojulie
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From: colorado usa
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Recently post-partum myself I can empathize with this woman. It is more probable that she has abdominal dysfunction (especially TVA) and is in a facet compression position of her lumbar spine. Unilateral psoas and rectus tightness may be present explaining the "apparent" sacral position changes (I don't think it moves much either)...
Thomas test is terrible for someone who is in this state. Try positions where you are taking one leg into extension with the other hip flexed to prevent the spine from extending. Either in prone or in sidelying to get a more reliable indication of anterior hip flexibility.
I read an interesting TVA exercise yesterday may be good to try on post partum women... have her lie prone over a slightly inflated BP cuff (place it between her ASIS). Have her engage her TVA (pull her abdomen inward) without moving or engaging her pelvis or trunk. See if she can reduce the BP cuff pressure by 10 mmhg. Once she is consistent with this motion, then start increasing challenge and make it more functional. Women especially after c-section are prone to TVA dysfunction and may overcompensate with the oblique muscle group without ever getting good TVA activation.
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Re: Sacral dysfunction - January 22, 2004 9:41:00 AM
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mcap56
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From: New York, NY
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Agreed. Julie is describing the TA test by Richardson, et al. This patient would benefit from the full program.
mcap
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Re: Sacral dysfunction - January 25, 2004 6:35:00 PM
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DC_Student
Posts: 24
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From: California
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Julie,
I was told to never place a patient in hip extension when relaxin may be present. Was this inaccurate info?
Thanks,
Nemo
[This message has been edited by DC_Student (edited January 25, 2004).]
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Re: Sacral dysfunction - January 25, 2004 6:44:00 PM
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ScottnKatiesDad
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Joined: December 18, 2001
From: Midland, TX USA
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I've been seing patients for 28 years and I am convinced that the SIJ is significantly overemphasized by some. Most of the "movements" are imagined. However, I have seen a small number of patients who did seem to have SI involvement and they typically respond to an SI belt (well worth a try) or to a contract-relax type exercise pulling one knee to the chest (typically done in a doorway). That exercise puts a rotational torque on the pelvis, but I don't even try to determine which way I think the SIJ should move, I try both sides and see if one helps. The last time I tried it (2 weeks ago) the first side I had the patient try completely relieved his pain. I just got lucky, but he thought I was amazing! The exercise probably has a name, but, at my age I'm doing well to remember my own name.
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Re: Sacral dysfunction - January 25, 2004 7:04:00 PM
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coloradojulie
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From: colorado usa
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I have never heard about the avoidance of hip extension with relaxin present. What would the contraindication be? Increased stride length? (just kidding, I am a little tired at the moment).
Actually I have been interested in a question lately...what is the "normal" hip extension range of motion, not including lumbar extension...pure hip...anyone?
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Re: Sacral dysfunction - January 25, 2004 8:28:00 PM
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kalindra61
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Joined: July 26, 2000
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The SI belt will only provide relief if worn while the pelvis is in the self-bracing position. If the pelvis is misaligned, it will actually hurt worse when wearing the belt.
The most famous SI guru would be Richard DonTigny. You can hardly read any articles about the SIJ without seeing his name in the bibliography.
His articles can be found at [URL=http://www.kalindra.com/sacroiliac.htm]www.kalindra.com/sacroiliac.htm[/URL] and he can be contacted thru the forum off that website.
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Re: Sacral dysfunction - January 25, 2004 8:49:00 PM
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BC_PT
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Joined: July 9, 2002
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Greg,
Thought I would add my 2 cents worth. You did not give a lot of information to go on, so some of this may not be relevant. Do the joints presently feel hypo- or hyper-mobile? Is the pain on one side or both? Is the pain on the side that feels more mobile or less so? Are there any obvious differences in the other Pelvic landmarks? What kind of muscle tightness is present in the back and lower extremities? What is the abdominal, lumbar and lower/extremity strength like? Is there anything problems in other areas? Lots of questions because there are lots of possibilities.
I would agree that the scientific literature is inconclusive, however, that does not mean that the METs are not useful. Often they need to be used along with other techniques - sometimes before, or during, or after the other problems have been sorted out.
Make sure there is no muscle tightness that is influencing the position of the ilia or sacrum. As mentioned already: the psoas, rectus, also, hamstrings, piriformis, quadratus, gluts. Make sure proper body mechanics are being used and that the lumbar-sacral stabilizers (as well as the lower extremities) are strong enough to help out. Abdominal and back strength are important as stated above, but check the hips and quads for any significant weakness that could influence the spine. Obviously a home program for this should be followed as well.
If the joint is hyper-mobile then it should be stabilized with a belt - and yes it is important to try to get the SI joints positioned in neutral before the belt is applied? If the joint is hypo-mobile, then it may need to be mobilize a bit. Teach them how to help "reposition" or mobilize the joints back to neutral if possible.
Make sure there are no lumbar disc or facet problems that need to be treated as well.
I often find that if an SI problem does not progress well after a few treatments, then I usually have missed something and/or the joint is hyper-mobile and it is going to take some time (with the use of the belt). The SI joint may or may not be the main problem. Except for a hyper-mobile SIJ, I usually find that this joint is not the source of the problem, although it may be the greatest source of pain. Most often I find the culprits to be muscle tightness and/or weakness in the lumbar-sacral spine and the lower extremities.
Hope this is useful, it is hard to be more specific without knowing more of the signs and symptoms,
BC_PT
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Re: Sacral dysfunction - January 25, 2004 10:02:00 PM
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nari
Posts: 1568
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From: Australia
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Here is my two cents' worth:
Post partum, we may well be looking at instability, so we need to stabilise until the hormones wear off. At the postnatal (and antenatal) clinic, the physios set their symptomatic women up with size K or L Tubigrip (also called Versigrip). Quite comfortable and easy to take on and off.
With other SIJ issues, I tend to agree with some of the posters - it is usually the lumbar spine which is the culprit.
I also agree with Colorado Julie about some TA work. It is pain-relieving as well.
Frequently, marked tenderness over one or both SIJs, may lead some astray. If the spine is appropriately treated, the SIJ symptoms often disappear.
Nari
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Re: Sacral dysfunction - January 26, 2004 3:54:00 AM
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Shill
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From: Madison WI USA
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ColoradoJulie,
I believe the hip extension range is no more than 20 degrees, according to the AAOS. But, then again, when have you ever seen an ortho surgeon actually measure with a goniometer?
No, wait, upon further review, the AAOS says 30 degrees. The range, in the opinions of all of the "authorities" is 10 to 50 degrees. Im leaning toward the 10 degree mark.
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Re: Sacral dysfunction - January 26, 2004 6:23:00 AM
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Diane
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From: Vancouver, B.C., Canada
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I would do what other posters suggest, and more: An area that has been overlooked so far is the pubic symphysis, where lower abs attach. If an illium is displaced backward making the right SI sulcus look deep, it may be that the right pube is sheared backwards, or torsioned upon the left one. One pubic bone can have quite a lot of motion relative to the other, and nothing can put them out of whack quite like the efforts of childbirth. I've noticed that problems here usually don't "hurt", but are tender and "pain" from them shows up further back. (The "culprit" might be situated quite far away from the "victim" in the body). The shear could be being maintained by an ab wall imbalance, usually rectus..
Soft tissue work on the lower abs, and some light muscle energy in supine using one or the other leg as a lever with a focus on restoring correct relationship between the two halves of the pubic bone can fix a lot of apparent problems at the back of the pelvis. I would suggest it is best to clean up any problems here BEFORE the relaxin is all gone away.
Diane
[This message has been edited by Diane (edited January 26, 2004).]
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Re: Sacral dysfunction - January 26, 2004 8:20:00 AM
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DocZon
Posts: 70
Joined: April 19, 2003
From: Winchester, MA
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I agree with what the others are saying.
Abdominal hollowing/bracing for the TA and continued stabilization with the Richardson protocol is great. The Glut. Max is the only muscle that attaches, although indirectly to the sacrum and ilium, so I would strengthen glut. max. Get her walking, both forward and backward. I would also check the QL's and either release them if tight or strengthen if weak.
There is a SI belt called the SI Loc which is pretty good, you can get them at OPTP. You should know pretty quickly if it works. Many patients will have immediate relief. If you can't wait until you get the belt, just wrap eleastic tubing around, slightly above the femur heads and over the anterior aspect of the pubic bone and have her walk around for a few minutes.
This is all assuming that she is "unstabile." Of course, manipulation can be helpful if indicated, check nutation and counter-nutation of the sacrum. If hip extension is limited and painful, that is usually a capsular problem. Just because she is 3 months post-partum w/ SI joint pain does not always mean a patient is unstable or has an instability at the SI joints. Could just be sacroiliitis.
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Re: Sacral dysfunction - January 26, 2004 2:12:00 PM
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DocZon
Posts: 70
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From: Winchester, MA
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Enlightened-
Your response was interesting. I will try it next time I have a patient with similar syptoms and findings as posted above.
I am curious to know about the type of scrutiny your procedure has gone through. While I understand that Motion Palpation has not faired well under certain cases of interexaminer reliability, the techniques can still be effective.
However, I was referring more to the work described in the text by Dos Winkel, author
of Diagnosis and Treatment of the Spine. He has quite a bit dedicated to manipulation/mobilization into counternutation. I will be happy to fax you the portion of the chapter. He is not concerned with the "scrutiny" that the procedure has undergone.
He does point out that "in most cases,it is impossible to determine whether an SI joint is locked in a nutated or counter nutated position. The simplist way is to start with a counternutation mobilization." That is all I am saying and it may be worth exploring. I am not familiar with the research behind SI belts and SI Locks but I know they can be effective in same cases. Should I never recommend an SI belt to anyone?
My comments and the comments of all the others, right or wrong should not be ingnored as you recommend. We are all intelligent individuals and we are all able to come to conclusions on our own. I mean, I am not telling this person to sprinkle magic healing dust over the SI joint and repeat a chiropractic mantra.
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Re: Sacral dysfunction - January 26, 2004 4:11:00 PM
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lmc74pt
Posts: 1
Joined: May 18, 2002
From: Orange Park, FL USA
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Greg,
I'm sure you have aquired some good answers to your questions by now, but I definitely agree with Shill. If your stuck on where to go next and are wondering if a technique will work or not, just do it and find out. (clearing all contraindications). How else are you supposed to learn? I see other Therapists 'over think' the problem and miss what's in front of them. In school, a mentor of mine would tell me "it's not brain surgery", find what's weak and strengthen it, and so on.
Okay, okay, my 2 cents is that I have had a good response from pts. using the force and form closure systems together to treat my SI pts. However, with your particular case have you tried using MREs of the hip adductors and abductors? Good luck. Look forward to hearing the outcomes.
ColoradoJulie, I learned in school that true hip extension is only 5-10 degrees
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Re: Sacral dysfunction - January 26, 2004 11:51:00 PM
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Brian2
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I can personally appreciate several aspects of the SI joint, because of problems that I have experienced.
Basically, I am strong and healthy, 49 yo. I am slender, 135# at 5-7, can lift 160# from about a foot off the floor. Simply to say that my back is basically okay. No real injuries, no structural abnormlities to my knowledge. My lumbar lordosis is too flat; my abdominals predominate. I try to hold more of a lordosis whenever I think about it.
But I have found that whenever I try to self-induce more stability at the sacral area, there is sharp pain at the SI joints, about 5-6/10. As I tighten my low back extensors as I am seated now (upright, on a firm seat, with my legs abducted at the sides of the seat), it hurts as I tighten them more and more. The pain subsides within 15 seconds after each tightening.
It used to be more sensitive, and I found myself automatically keeping my abdominals tense throughout the day, and having significant pain only when I tried to induce a 'normal' low back posture. Several times, I have noticed a sharp pain at either SI joint when running or perhaps at other times, if I recall correctly. Despite the surprising, sharp pain, I focused on tensing my low back muscles, and thereby controlled the pain, without exacerbation of the overall situation. I have also experienced sharp knee pain while jogging, and focused on using the muscles properly, believing that balanced muscle tone is basically the only thing that can control proper articulation of the joint surface. I believe proper articulation is necessary to prevent such problems known as osteomalacia patella and facet syndrome, for example.
Experience is a wonderful teacher... it lends credibility to a problem, in our own mind. Based on my own experiences, I believe;
1) the amount of visible, gross movement of the pelvis which causes or relieves SI pain can be very slight. In my case, it is basically a matter of whether my muscles are tense or not. Neither position, if it could be measured, would be considered abnormal or pathologic.
2) Pain tends to inhibit proper muscle support of the joint. ie, when we hurt, our muscles tend to go lax, and joint surface integrity is lost, and pain continues.
3) I read some of the comments about the use of an SI belt. I would have concerns, in general, because we would be tending to gap the bilateral surfaces of the SI joint that are nearest each other. Yes, we might be minimizing movement, but don't you imagine that we are truly disrupting the integrity of the joint in the process? Along the lines of MFR, we would be applying a prolonged stretch to the soft tissues, which could be very potent in lengthening them.
4) One thing that I did find helpful, was to do some weight lifting, specifically dead lifts, paying close attention to my body mechanics, especially my low back/ sacral posture, sticking my rear end out what felt like too far. That simply strengthened those muscles to better hold my posture. As I said, my abdominals tend to be my forte, and my back extensors evidently tend to be weak.
5) For relief of local soft tissue/muscle spasm which may be affecting that or any other area, my preferred treatment is MFR. My approach may be unorthodox, but have your patient comfortably in supine, on a soft-enough surface for the treatment. I do home care, so a bed is usually used, as opposed to a clinic mat which may be too unyielding. Your hand would be palm-up, cradling one or both SI joints. Now, I do slow MFR treatments. Maintain moderate contact pressure, and just wait. You will eventually feel as if the soft tissue has something moving inside it. It will move first one way, then another. It may stop for awhile, then start up again. The signal that the release is 'done', is that the body part will start to move in sync with the patient's breathing. But it you hold longer, it may stop awhile, and start up again, as (I imagine) more of the interrelated soft tissue becomes (balanced) with that area you are treating. I don't doubt your being skeptical; all I can say is that I have used MFR for more than 10 years, on more than half my patients, and it almost does not fail to provide significant results, and change from treatment to treatment, in the presentation of the problem. It is not unusual for me to spend my whole visit on MFR, even one area, but the results justify this. MFR done in this way, at this area, will not be focused on any particular direction of correction. It is facilitating relaxation of the soft tissue, realxing it in ways that I do not think that I could anticipate. If assymetry is the issue, I would look for restrictions in other areas, but I would not try tweaking the SI joint per se.
6) Your patient is probably sitting a lot. I think all seating leaves something to be desired. If her SI joint is unsupported, it is in a position of strain. Ligaments are being overstretched, and joint surfaces are being pressed together in a non-anatomic, non-congruent position. The ligaments will be painful (bending under the hood of a car, it hurts when you straighten up. The ligaments are screaming at that time. They generally subside after a little while. But what if you do not straighten up? You develop chronic pain, pain that is less if you remain bent over. I think this the etiology of poor posture.)
Chairs commonly have just a few pieces of wavy, maybe 3/16" wire-- very inadequate support. To demonstrate, have your patient sit in a chair, and you provide the sacral support manually by slipping your hand behind the sacrum. Support it firmly. Almost invariably, the patient will say that it feels good, and realize what they are missing from their chair. I have used a folded handtowel or larger, to fit at the sacrum, to provide support. Experiment; it may be hard to find a satisfactory solution. The 'ultimate' solution is for the person to become strong enough to control the joint position. People slouch. Soft tissue at the buttocks does not affort a firm surface to brace. Above all perhaps, the body was not meant to be sedentary; joints and muscles were meant to move, bones were meant to receive intermittent compression, etc.
So, I would deal with the pain with MFR, focus on strengthening, posture, body mechanics. If the pain persists with patiently, properly applied MFR, then consider that the etiology has not been resolved.
My approach to musculoskeletal problems is essentially to relax restrictions, to normalize strength and tone and posture and ROM and movement patterns. My thought is simply, if everything is healed, and there is no actual lesion, and there is no tension, then what is there left to cause pain?
Brian
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