Sacroiliac joint dysfunctionVahid.marouf PT

Iliosacral Dysfunctiony Innominate Rotation:

Anterior(forward) Posterior(backward) y Innominate Shear: Upslip (Superior innominate shear) Downslip(Inferior innominate shear) y Iliac Out flare & In flare

Sacroilliac Dysfunctiony Nutation & Counter nutation y Sacral Torsions

Forward Sacral Torsion Left on Left Right on Right Backward Sacral Torsion Right on Left Left on Left y Unilateral sacral Flexion

Anterior Innominate Rotation

Treatmenty Backward Rotation for Anterior Iliac Dysfunction y For anterior innominate rotation dysfunction, signs on the y y y y

involved side are as follows: Superior and anterior PSIS Inferior and posterior ASIS Positive Standing Flexion Test ,long sitting test,prone knee flexion test Apparent Lengthening of leg in supine

JOINT MOBILIZATION TECHNIQUES

y Patient Position: y Supine with the leg opposite to the side to be

mobilized hanging over the edge of the table. y Therapist Position: y Stands on the side to be mobilized. y Motion: y The therapists cephalic hand cups the ASIS in the palm while the caudal hand grasps the ischial tuberosity. y Transfer your weight toward the patient's head; this results in a backward rotation of the innominate on the sacrum.

Advantages: Technique can be modified to use muscle correction, which can place a posterior rotatory moment on the innominate (muscle energy) using the gluteus maximus as the desired force. Have the patient resist a force provided by your trunk (or against the patient's own hands, which fixates the knee) with a sustained submaximal contraction for 7 to 10 seconds. This is repeated three or four times, not allowing the hip to move into extension, only flexion

y Self Mobilization to counteract Anterior Iliac

Dysfunction y Self treatment technique to counteract anterior iliac dysfunction consists of following techniques: y Standing:y The patient places the foot on a table or bench, leans

toward the knee, and stretches it into the axilla. y Repeat this exercise several times a day and always making a correction when going to bed to relieve the strain on the involved ligaments. y These techniques are powerful rotators of the innominate and can be overdone unless specific guidelines are given.

Supine:

y Standing Bending

Forwards: y Method to correct right anterior rotation: a right posterior lever effect can be created by resting right foot on a high stool (hip flexed 90 and abducted 45), and then letting the trunk hang down in forward flexion as far as feels comfortable.

Posterior Innominate Rotation

Treatmenty Forward Rotation for Posterior Iliac Dysfunction y For posterior innominate rotation dysfunction, signs on the y y y y y

involved side are as follows: Inferior and posterior PSIS Superior and anterior ASIS Positive Standing Flexion Test Apparent shortening of leg in supine Hypermobility or restriction in innominate anterior rotation

y Patient Position: y Supine with the leg on the side to be mobilized extended y y y y y

over the edge of the table. Therapist Position: Stands opposite of the side to be mobilized. The patient or therapist flexes and stabilizes the opposite leg. Motion: Place the caudal hand over the thigh and use it to push the hip into further extension; the cephalic hand can be applied to the patient's PSIS, pushing upward to increase the forward rotation of the innominate on the sacrum.

y Advantages: y Technique can be modified to use

muscle correction, which can place an anterior rotatory moment on the innominate (muscle energy) using the iliopsoas as the desired force. y Have the patient push the freely hanging leg up against your hand with a submaximal force while you give unyielding resistance to the contraction for 7 to 10 seconds. y This procedure is repeated three or four times or until all the slack is taken up.

y Self Mobilization to counteract Posterior Iliac

Dysfunction y Self treatment technique to counteract posterior iliac dysfunction consists of passive hip extension in prone or supine.

y In the supine correction technique it

is important that the (left) leg is off the table. y The hip should be maximally adducted and literally be suspended above the horizontal by the hip capsule and soft tissue. y This position should be held for about 2 minutes.

Iliac Inflare

y Mobilization for Innominate y y y y y

y y

Inflare Patient Position: Prone with leg externally rotated Therapist Position: Stands on the left side. The cephalad hand contacts the medial aspect of the left ASIS and the caudad hand contacts the area just lateral to the PSIS. Motion: The cephalad hand pulls the ASIS laterally and inferiorly while the caudad hand applies medial and superior force to the PSIS.

Muscle Energy Techniques

Iliac outflare

y Mobilization for y y y y y

Innominate Outflare Patient Position: Prone Therapist Position: Stands on the left side. The caudad hand contacts the left ankle and the cephalad hand the right side of the sacral base.

y Motion: y The cephalad hand applies

postero-anterior pressure to the right side of the sacral base. y The caudad hand internally rotates the left hip to inflare and internally rotates the left innominate.

y Self Mobilization for

Innominate Outflarey The patient lies on her back and

bends the involved hip to 90. y With her hand, she pushes the thigh to the opposite side. y A cushion or folded pillow under the foot and lower leg may be necessary to maintain 90 of hip flexion. y The stretch is maintained for 2 minutes

MET

Upslip

y Inferior Glide for Innominate Upslip y An upslip is a superior subluxation of the innominate on the

sacrum at the SU. The dysfunction is primarily articular with secondary muscle imbalances (as opposed to anterior and posterior innominate rotations, which primarily result from muscle imbalances that secondarily restrict SIJ motion). Signs on the involved side include y Superior positioning of the ASIS, PSIS, iliac crest, pubic tubercle, and ischial tuberosity. y Inferior Glide of ilium is restricted.

y Patient Position: y Prone y Therapist Position: y Stands to the involved side at the

head.

y Motion: y The outer hand contacts the superior

aspect of the iliac crest and applies an inferior and slightly medial force in the plane of the joint.

y Distraction in supine

y Distraction in prone

y Self Distraction in standing

Nutation & Counter nutation

y Sacral Nutation Technique y This is used to reduce a sacral counternutation positional fault,

y y y y y y

commonly caused by a postural flat back, or flexed sitting or standing postures and coccygeal muscle spasm. Signs include Lumbar spine hyperflexion Shallow (posterior) sacral sulci Deep (anterior) inferior lateral angles, Less prominent PSIS Sacral flexion restriction L5 to S1 (and possibly generalized) restriction in lumbar extension

y Patient Position: y Prone with pillow under the abdomen y y

y y

y

y

and the legs externally rotated Therapist Position: Stands at the level of the pelvis on the involved side, facing the foot of the table Motion: The base of the inner hand contacts the sacral base, with the arm directed at a right angle to the base. The mobilizing hand glides the cranial surface of the sacrum ventrally, directing the sacrum into nutation. Incline the pressure toward the patient's feet.

y Sacral Counternutation Technique y This is used for sacral nutation dysfunction, commonly

y y y y

caused by an increase in the lumbosacral angle because of structure or poor abdominal tone combined with lumbar spine hyperextension and a weak gluteus medius and maximus. Signs include Deep (anterior) sacral sulci and shallow (posterior) inferior lateral angles Increased piriformis and psoas tone Sacral flexion hypermobility or sacral extension restriction Possibly tenderness and tightness bilaterally in the tensor fasciae latae

y Patient Position: y Prone with legs internally y y y y

rotated Therapist Position: To one side of the pelvis, facing the head Motion: With thenar or ulnar contact of the inner hand on the sacral apex, apply a postero-anterior force on the apex of the sacrum when the sacrum is felt to extend.

Sacral Torsion

y Sacral Right Side-bending Technique for

Left-on-Left Sacral Torsion Dysfunction

y y y y y

A. Sacral Right Side-bending Patient Position: Prone Therapist Position: Stands on the right side of the patient facing the feet. y The ulnar aspect of the left hand contacts the posterior aspect of the left side of the sacrum with the fingers pointed toward the feet. y Motion: y An inferior, slightly medial force is applied onto the left side of the sacrum by taking up tissue tension on the posterior aspect.

y Sacral Right Rotation

Patient Position: Prone Therapist Position: On the right side of the patient with the ulnar aspect of the right hand on the posterior aspect of the left inferior lateral angle. The left hand contacts over the PSIS of the right ilium. Motion: The right hand applies postero-anterior force to the posterior aspect of the left inferior lateral angle, and the left hand applies antero-lateral force to the right ilium for stabilization.

y Self Treatment of Left Sacral Rotation

The patient lies supine with the hips and knees flexed. A padded dowel (2/5 cm x 10 cm) is placed vertically on the left side of the sacrum to encompass L5-S 1 and S1S3. The patient maintains this position for 2 minutes. After treatment, retest mobility.

MET(forward sacral torsion)

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