Escolar Documentos
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DPT 631
Musculoskeletal Examination and Intervention for the Neck and Trunk
SIJ EXAMINATION & INTERVENTION
Peter Huijbregts, PT, OCS, FAAOMPT
ANATOMY
A. Osteology
B. Arthrology
• L-shaped auricular surfaces with a shorter superior, vertical portion on the lateral surface of S1 and a longer inferior,
more horizontal part extending across S2 (S3).
• Inter- and intra-individual (left-right) differences (Bernard and Cassidy, 1991).
• Sacral cartilage typical hyaline cartilage.
• Iliac cartilage may resemble fibro-cartilage; histologically it is also hyaline cartilage (Bernard and Cassidy, 1991).
• Joint surface texture: non-complimentary cartilaginous irregularities increase friction coefficient (Vleeming et al, 1990).
• Confuting reports in literature re: reciprocal ridges and gutters on joint surfaces.
• Possible accessory (supernumerary) sacroiliac joints in 8 to 36% of the population (Bernard and Cassidy, 1991). They
may be syndesmoses or synovial joints. They can occur single, double, or triple (Schunke, 1938). Their joint plane
orientation may vary up to 60% with auricular joint plane (Walker, 1992).
C. Ligamentous structures (Alderink, 1991; Gray and Clemente, 1984; Willard, 1997)
• Interosseus sacroiliac ligament: located between the sacral and iliac tuberosities, dorsocranial to SIJ; may blend with
posterior SIJ capsule.
• Ventral sacroiliac ligament: thickening anterior SIJ capsule.
• Short posterior sacroiliac ligament: runs nearly horizontal from first and second transverse tubercle on dorsal surface
sacrum to iliac tuberosity.
• Long posterior sacroiliac ligament: covers short posterior sacroiliac ligament; runs from second to fourth transverse
tubercle to PSIS.
• Sacrotuberous ligament:
1. Lateral band connects PIIS to ischial tuberosity.
2. Medial band runs from lateral coccyx to ischial tuberosity.
3. Superior band runs from PSIS to lateral coccyx.
4. Central bands run between lateral band and the fourth and fifth transverse tubercles of the sacrum.
• Sacrospinous ligament: lower lateral sacrum and coccyx to ischial spine.
• All ligaments resist nutation; only the long posterior sacroiliac ligament resists counternutation.
D. Myology
• Role and anatomical connections of the thoracolumbar fascia (TLF) as described earlier.
• Dorsal sacroiliac ligaments connect medially to the TLF (Alderink, 1991).
• Tendons of the deepest lamina of the multifidus muscle extend into sacrotuberous ligament (Willard, 1997).
• Piriformis and gluteus maximus muscles are continous with sacrotuberous ligament (Vleeming et al, 1989).
• Biceps femoris tendon is continous with sacrotuberous ligament (Vleeming et al, 1989; Van Wingerden et, 1997).
• Sacrospinous ligament is attachment site for pubococcygeus muscle (Gray and Clemente, 1984).
• Extensions of the aponeuroses of the transverse abdominis, rectus abdominis, pyramidalis, internal oblique, adductor
longus, and graciis muscles reinforce the anterior pubic ligament (Kapandji, 1986); due to distance to SIJ these muscle
can exert strong stabilizing compressive moments on SIJs
BIOMECHANICS
B. Research summary
• Joint surface orientation, joint surface irregularities, and ligamentous laxity determine type and extent of movement
available in SIJ (Weisl, 1954; Wilder et al,1980)
• Pure translation or rotation can only occur in SIJ if sufficient ligamentous laxity allows for unlocking joint surfaces;
distraction of 7.25 mm needed for pure translation to occur (Wilder et al, 1980).
• Research shows main motion occurring in SIJ is (counter)nutation; these movements take place mainly in the sagittal
plane.
• The three-dimensional orientation of the joint surfaces may explain apparent minimal rotation/translation observed
around other two orthogonal axes/planes, i.e. movements in the transverse plane (inflare and outflare) or motions in the
frontal plane (upslip and downslip) (Huijbregts, 2001a).
• Osteopathic concepts may have a role in explaining mobility in SIJ allowing excessive mobility (Huijbregts, 2001a).
• “A unifying model of sacroiliac function has not been presented, supported, or verified…” (Alderink, 1991).
• However, perfect form closure does not allow for SIJ movement; it would not allow the SIJ to dissipate forces
converging in the pelvic region; a combination of force and form closure does allow for movement.
• Force closure: lateromedially directed forces are needed to increase intra-articular friction and thus resist the shear forces
resulting from vertical lumbosacral loading (Snijders et al, 1997).
• Because of the existence of force closure the body needs a system to control SIJ mobility: this system has ligamentous,
muscular, and of course neural components.
• Trunk flexion results in sacral nutation. This nutation provides for stability due to the self-locking mechanism (Colachis
et al, 1963; Stureson et al, 1989; Stureson, 1997).
• Trunk flexion in standing increases hamstrings muscle tension. This adds to SIJ stability by increasing sacrotuberous
ligament tension and force closure (Vleeming et al, 1997).
• Counternutation sometimes hypothesized to occur near the end of flexion (Lee, 1999) unlikely.
• Delordozation or adopting a flat back posture in standing may cause sacral counternutation (Vleeming et al, 1997).
EXAMINATION
• The biomechanical classification system uses the extrapolation of (patho)anatomical and (patho)biomechanical
knowledge to guide examination, diagnosis, and treatment.
• Face validity and construct validity may seem high.
• However, reliability and validity (sensitivity and specificity) of physical tests often unproven or questionable.
A. Provocation tests
• In the biomechanical system negative provocation tests are used to rule out SIJ dysfunction.
• Positive tests do not necessarily implicate SIJ as source of symptoms: as discussed in the examination of the lumbar
spine, we need to clear the lumbar spine and hip before we can assume with more certainty that positive SIJ provocation
tests implicate the SIJ as the source of symptoms.
• Discussed previously: distraction test, compression test, thigh thrust test, pelvic torsion (Gaenslen) test, sacral thrust test.
• Meadows (1999) classified the distraction and compression tests as primary provocation tests: positive tests indicate a
more irritable SIJ. Intervention consists mainly of anti-inflammatory modalities and (relative) rest.
• Palpation of bony landmarks: ASIS, PSIS, iliac crests, and greater trochanters. Patient is standing, therapist sits on stool
behind (and in front) of the patient. These tests give information on functional leg length differences (greater trochanters)
and innominate position. Innominate positional faults are posterior and anterior innominate rotation and inferior or
superior translation. They do not provide information as to the presence of dysfunction or the side of dysfunction.
• Question: A patient presents with equal greater trochanter and iliac crest levels, lower right PSIS, and lower left ASIS.
What is the dysfunction present?
1. Posterior right innominate rotation.
2. Anterior left innominate rotation.
3. A combination of the previous two dysfunctions.
4. No dysfunction.
• Osteopathic concepts include positional palpation of the sacral sulcus (the area just medial to the PSIS) and the inferior
lateral angle (the lateral inferior pole of the sacrum) to determine sacral rotation and sidebending positional faults. These
tests are usually done with the patient prone.
• Remember the poor intra- and interrater reliability of positional tests (O’Haire and Gibbons, 2000)
• Combining active motion palpation tests with provocation tests may give a better indication of the symptomatic side.
Decreased mobility in the left SIJ with a positive provocation test for the left SIJ implicates left SIJ hypomobility.
Decreased left mobility with a right positive provocation test may implicate a symptomatic right hypermobility and
normal mobility left.
• Poor reliability.
Standing flexion test (Meadows, 1999; Van der El, 1992; Winkel, 1991)
• Test: palpation of relative movement of both bony landmarks during trunk flexion.
• Normal response: the S2 spinous process initially moves upward and forward relative to PSIS (sacral nutation), then
relative movement stops and PSIS moves upward and forward (hip flexion).
• Positive test: asymmetry in relative motion S2-PSIS when comparing sides.
• False positive tests: may result from SIJ asymmetry, bony pelvic asymmetry, rotation position lumbar vertebrae,
differences in hamstrings muscle length, or leg length discrepancies.
• (Alternative test #1: seated flexion test eliminates leg length discrepancies and effect of hamstrings muscle length.)
• (Alternative test #2: palpation of both PSIS allows for direct comparison between SIJs.)
Gillet test (Magee, 1997; Meadows, 1999; Van der El, 1992)
• Test: palpation of relative motion between landmarks during ipsilateral hip (and knee) flexion; patient is allowed to hold
on to support to help with balance.
• Normal response: PSIS initially moves downward and backward relative to S2 (posterior innominate rotation), then
relative movement stops and both landmarks move together.
• Positive test: asymmetry in relative motion S2-PSIS when comparing sides.
• (Alternative test: palpation of both PSIS during hip flexion; due to body weight causing self-locking on side of the stance
leg no motion should be available there.)
• Question: during the standing flexion test with palpation on both PSIS, the right PSIS moves upward and forward sooner
than the left PSIS. What is the dysfunction present?
1. Right SIJ hypomobility.
2. Left SIJ hypermobility.
3. A combination of both dysfunctions above.
4. A shorter left hamstrings muscle.
• Question: What is the most appropriate test to determine the side of a possible SIJ dysfunction in the case of positive
findings on the active motion palpation tests?
1. Positional palpation tests.
2. Provocation tests.
3. Passive physiological motion tests.
• Describe the findings on all active motion palpation tests in case of:
1. A left SIJ hypomobility without positional fault.
2. A left SIJ hypomobility with a posterior innominate rotation positional fault.
3. A right SIJ hypermobility.
• Together with provocation and positional palpation tests (and active motion palpation tests) can indicate location (side)
and direction of hypomobility.
• Question: provocation tests cause pain in the left SIJ region. Positional palpation reveals a higher left ASIS and a higher
right PSIS; iliac crests and trochanters are equal. The standing flexion test revealed a relative hypomobility of the left
SIJ. The left anterior innominate rotation test is restricted with a hard capsular endfeel. The left posterior innominate
rotation test is normal. What is the most likely dysfunction present?
1. Right sacroiliac hypermobility.
2. Left anterior innominate rotation restriction due to capsuloligamentous shortening.
3. Left posterior innominate rotation restriction due to capsuloligamentous shortening.
• Question: are the positional palpation results necessary to make your diagnosis?
• These tests do not allow us to make a decision as to which subsystem is deficient. Remember that active and neural
control subsystem deficiency may affect force closure and therefore stability without passive subsystem deficiency.
• Further tests are needed to determine (type of) contribution of the different subsystems, e.g. structural stability and
muscle function tests (discussed later).
• Question: the patient complains of sacroiliac region pain with ADL. The therapist has the patient perform the supine
straight leg raise left. It is painful and the patient appears to have problems lifting the leg. Increasing force closure
decreases pain and increases the ease of motion. What dysfunction is likely at this point in the examination?
1. A right sacroiliac instability.
2. A left sacroiliac passive subsystem deficiency.
3. A left sacroiliac active subsystem deficiency.
4. A left sacroiliac neural control subsystem deficiency.
• Question: the patient reports pain in the SIJ region. Provocation tests were all positive. Active and passive motion
palpation tests reveal no hypomobility. Positional palpation is normal. Stability screening tests are painful, yet increasing
force closure does not affect or even increases the complaints. What is the most likely explanation?
1. Insufficient force used for force closure.
2. Inflammatory lesion SIJ causes pain with compressive force applied.
3. Complaints are not related to SIJ.
• In the biomechanical system, accessory motion tests are used to assess the motion behavior of a joint by way of attention
to the glides associated with its (angular) physiological motions.
• E.g. decreased glenohumeral abduction with normal caudal glide of the humerus in the restricted position excludes
capsuloligamentous restrictions as the cause of the restriction in physiological motion.
• E.g. decreased trunk flexion with a hard endfeel and decreased motion on low lumbar P/A implicates the
capsuloligamentous structures of the lumbar spine.
• Stability tests can implicate joint instability. This instability is generally the result of traumatic or degenerative changes.
Instability tests attempt to assess motions that should not be possible in a normal joint.
• Testing the accessory motions of the SIJ is impossible: research shows that translatory motion only occurs in the case of
capsuloligamentous laxity. Therefore, tests of the accessory motion theoretically available in the SIJ double in this case
as our stability tests.
• PAM tests will normally show very minimal motion: the biomechanical system uses the endfeel on this very minimal
motion to diagnose the type of hypomobility possibly present (Meadows, 1999).
Dorsal innominate shear test (same as posterior shear/thigh thrust practiced with SIJ scanning)
• Patient position: supine, ipsilateral hip flexed to approximately 90 degrees and slightly adducted.
• Therapist position: standing contralateral of the side to be tested.
• Hand placement: distal hand palpates both PSIS and sacral surface, proximal hand placed on the ipsilateral knee of the
patient.
• Test: take up slack SIJ by sustained axial compression through femur attempting to shear innominate dorsally on sacrum.
• Positive test: motion between sacrum and innominate indicates passive subsystem deficiency.
• Remark: similar to the thigh thrust test described as a provocation test with the exception of sustained pressure and
palpation at the SIJ joint line.
• May involve length, strength, endurance, and coordination tests of all muscles contributing to force closure.
• May include multifidus and transverse abdominis muscle tests described by Richardson et al (1999).
• Do not forget the effects of lower extremity muscle imbalance on load transfer through SIJ. E.g. left gluteus medius
weakness may result in a left Trendelenburg gait with increased vertical shear forces applied to the left SIJ.
DIAGNOSIS
• The only tests seemingly reliable and valid for SIJ dysfunction are some of the provocation tests.
• Positive provocation tests may implicate or exclude the SIJ as a source of complaints, but provide no further information
on appropriate interventions.
• Diagnosis and treatment are based solely on extrapolation of (patho) anatomical and (patho)biomechanical knowledge.
• The assumption that hypomobility can only occur as a result of an underlying instability, means that we always need to
diagnose and treat instability in all SIJ-dysfunctions.
• SIJ dysfunction classification is theoretical and not standardized across all therapists (Huijbregts, 2001b).
• The dysfunction presented is also based on the assumption that only innominate rotation and translation dysfunctions are
relevant.
• An SIJ biomechanical diagnosis includes:
1. Location: left, right, or bilateral.
2. Type of hypomobility: extra-articular, capsuloligamentous, or pathomechanical.
3. Direction of hypomobility: anterior innominate rotation, posterior innominate rotation, inferior innominate
translation, superior innominate translation, or combinations.
4. Underlying type of instability: combined subsystem or active/neural control subsystem deficiency.
C. Pathomechanical hypomobility
• Inferior and superior translation make it very hard for the patient to bear weight on the affected leg (Meadows, 1999).
• Inferior and superior translation may indicate greater instability (Lee, 1999).
• Assymetry of motion on active motion palpation tests.
• Hypomobility on PPM tests.
• Pathomechanical endfeel with even more restricted ROM on PAM tests.
• Positive functional stability and muscle function tests.
D. Capsuloligamentous hypomobility
E. Extra-articular hypomobility
TREATMENT
A. Pain modulation
• Can include physical modalities (e.g. thermotherapy, diathermia, cryotherapy, ultrasound therapy) or grade I and II
oscillatory techniques.
• Sacroiliac belt may minimize strain SIJ tissues (Vleeming et al, 1992).
• ADL advice to decrease torsional strain on SIJs: careful with reciprocal movement pelvic region (walking, running,
stairs), excessive hip abduction during intercourse, unilateral loads (lifting in sidebent or rotated position, standing on
one leg).
B. Manual mobilization
• For the entry-level clinician, both pathomechanical and capsuloligamentous hypomobilities can effectively be treated
with manual mobilization (grade III, IV, and sustained endrange) and/or muscle energy techniques.
• Described are techniques to affect innominate rotation and/or superior or inferior translation.
Anterior innominate rotation mobilization #2 (Van der El et al, 1993; Winkel, 1991)
• Patient position: prone with the trunk extended, sidebend and rotated towards affected SIJ, as close as possible to the
contralateral side of the bed.
• Therapist position: standing on the contralateral side.
• Hand placement: cranial hand is placed on the iliac crest at the PSIS, the caudal hand is placed on the ventral-distal thigh
and lifts the leg, close packing the hip into extension.
• Mobilization: the cranial hand pushes in a ventral-proximal-lateral direction.
• Variation: by placing the foot of the non-affected side on the ground on the foot of the therapist the unaffected SIJ is also
locked.
C. Stabilization
• May include strength, endurance, and coordination training of all muscles capable of increasing force closure.
• May also include coordination training of local muscle system of the lumbar spine (multifidus and transverse abdominis
muscles).
• Sacroiliac belt or tight fitting spandex pants may increase force closure SIJ.
• A flat back posture may cause sacral counternutation with resultant failure of self-locking (Vleeming et al, 1997).
• Addressing the causal dysfunction responsible for the flat back posture is necessary to affect SIJ dysfunction, e.g. a post-
partum painful symphysis pubis, a painful zygapophysial joint dysfunction, a posterior disk lesion, stenotic syndromes,
muscular dysbalances, etc.
• Restrictions in the lower extremity may increase the load on the SIJ.
• E.g. decreased hip extension (whether capsular or muscular) will decrease contribution hip during late stance phase
possibly increasing anterior innominate rotation with decreased self-locking.
• Weakness and dyscoordination in the lower extremity may affect SIJ function.
• E.g. excessive pronation may cause internal rotation of the tibia leading to internal rotation of the femur. This will
decrease hip contribution in late stance, but also affect piriformis length and hip abductor efficiency.
• Neurologic deficits due to lower lumbar radiculopathy may affect the SIJ mechanics.
• E.g. L5 weakness may affect gluteus medius, S1 weakness may decrease gluteus maximus strength.
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