0000-0000/79/0001~0023$02.

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THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY
Copyright O The Orthopaedic and Sports Medicine Sections of the American Physical Therapy Associaton

Dysfunction of the Sacroiliac Joint and

Its Treatment*
RICHARD L. DONTIGNY,
BS, PTt

A very common but frequently overlooked cause of pain in the low back is a result
of leaning forward without adequately supporting the anterior pelvis. This allows
the innominates to rotate slightly downwards on the sacrum with fixation and an
apparent increase in the length of the legs, which in turn irritates the sciatic nerve.
This commonly occurs bilaterally but may occur on just one side. Flexion of the
innominate(s) on the sacrum restores function to the sacroiliac joint, causes an
apparent shortening of the legs and gives excellent relief of pain in the low back
and sciatic pain.
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Pain in the low back has been diagnosed and from the abdominal muscles. Contrary to some
misdiagnosed, treated and mistreated for dec- myths, man was beautifully designed to stand
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ades. The purpose of this article is to take a erect.

fresh look at pain in the low back, to describe Dysfunction occurs, not just during lifting, but
the forces that precipitate the pain, to demon- when the patient leans forward or stands with
strate a very simple method of relieving the pain lordotic posture. This causes the line of gravity
and preventing recurrence, and to detail the to be displaced anterior to the center of the
conservative management of the problem. acetabula7.l5creating a rotational force in exten-
"In a Columbia-NYU study of 5,000 unse- sion around the acetabula (Fig. 2). If anterior
lected back pain cases, muscle weakness or pelvic support from the abdominal muscles is
inelasticity was found to be the cause of pain in adequate, there is no problem. If, however, sup-
Journal of Orthopaedic & Sports Physical Therapy®

81 percent. All other causes-including her- port from the abdominal muscles is not ade-
niated intervertebral disk, tumor, arthritis, frac- quate, the anterior pelvis rotates downwards
ture, bone abnormality-made up only 19 per- around the acetabulae. This anterior rotational
cent."I6 It will not be within the scope of this force tends to rotate the innominate bones an-
article to discuss the management of disks, tu- teriorly on the sacrum, but because the sacrum
mors, arthritis, or fractures, but rather the treat- is placed within the innominates and is wider
ment of the other 81%, where physical therapists anteriorly than posteriorly, the innominate bones
can be most effective. tend to spread on the sacrum. On reaching the
limit of their motion, they wedge and lock.
MECHANISM By superimposing Figure 1 over Figure 2 (Fig.
3) we can see how the relationship of the ace-
During normal standing posture the line of tabulum to the sacroiliac joint is changed. As the
gravity passes slightly posterior to the center of acetabulae move downwards and slightly pos-
the a ~ e t a b u l a .23
~ ~When
. the preponderance of teriorly it causes an apparent lengthening of the
the weight of the upper trunk is carried on the legs. More common bilaterally, it frequently oc-
posterior pelvis, the pelvis rotates downward curs unilaterally, causing pelvic obliquity and a
posteriorly, around the acetabula, creating a ro- high iliac crest on the same side when the patient
tational force in flexion (Fig. 1). A pelvic tilt is is standing." L a r ~ o expressed
n~~ the belief that
created automatically, with little or no assistance the presence of a lumbar convexity on the side
of the long leg depends on a sacroiliac lesion
* From the Northern Montana Hospital. P. 0. Box 1231.Havre, MT
59501. being present on that side.
t Chief Physical Therapist. The apparent leg length difference, and thus
 DONT'IGNY Vol. 1, No. 1

proximately the same as or more than that of the

acetabulum.
Several authors have described anterior dys-
function of the sacroiliac joint, but some have
referred to it in different terms such as "forward
torsion sprain" or "sacroiliac slip".8, 18. 24. 26-28

EVALUATION AND CORRECTION

The passive straight leg raising test is most

helpful in the evaluation of pain in the low back.
Pain down the leg on passive straight leg raising,
which is exacerbated by dorsiflexion of the foot,
is indicative of sciatic nerve pain. Despite a study
to the contrary by Danforth and W i l ~ o n , several
'~
researchers have found a relationship between
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sciatic nerve pain and pain in the sacroiliac

joint.l 8. 38. 40
Fig. 1. Sacroiliac region in normal posture. Arrows indicate
normal rotation force in flexion. (Courtesy of The D.O.) When the leg is raised, the pull of the ham-
strings on the innominate bone causes a poste-
rior torsion strain on the same side.27If this does
not increase the pain in the back or if it eases
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

the pain in the back, anterior dysfunction should

be suspected. If passive straight leg raising
causes pain or increases the pain on the same
side, suspect a posterior or vertical complication.
If passive straight leg raising causes pain on the
contralateral side, suspect anterior dysfunction
on the opposite side (rotating one innominate
Journal of Orthopaedic & Sports Physical Therapy®

Fig. 2. Region in lordotic posture. Reversal of rotation force

around the acetabula with anterior shift of the line of gravity
can be seen. (Courtesy of The D.O.)

the amount of excursion of the acetabulum, on

the involved side can be measured from the
posterior superior spine of the ilium to the medial
malleolus and compared before and after cor-
rection or compared with the same measurement
on the uninvolved side. Differences are usually
from 3/8-5/8 in (1 -1.5 cm). Measurements from
Fig. 3. Overlays of pelvis. Dotted line indicates position of
the anterior superior spine to the medial malleo- the pelvis in lordotic posture and solid line that in normal
lus are not relevant in themselves because the posture. Movement of the acetabula can be seen. (Courtesy
excursion of the anterior superior spine is ap- of The D.0 . )
 Summer 1979 DYSFUNCTION OF SACROILIAC JOINT 25

posteriorly, increases anterior dysfunction on An alternative method may also be used. The
the opposite sidez7). therapist stands facing the right side of the table
The most consistent sign that confirms the and passively flexes the patient's right hip and
suspicion of anterior dysfunction is the manner knee along side of the chest toward the patient's
in which the leg seems to shorten when the axilla (Fig. 4), stretching slowly and firmly with
innominate is flexed on the sacrum. "If anterior the left elbow on the patient's right knee and
dysfunction of the sacroiliac joint is suspected, grasping the patient's right ankle with the left
an evaluation should be made to see if there is hand. With the right hand, the therapist may
an apparent lengthening of the leg. The patient either hold down the opposite leg, or grasp the
is placed supine on an examination table and his patient's right ischial tuberosity and pull it up-
hips and knees are flexed toward his chest to ward, reinforcing the posterior rotational force
flatten the lumbar spine, to minimize pelvic obli- while a colleague holds the left leg down on the
quity, to make sure the buttocks lie evenly and examining table (Fig. 5). Then slowly lower the
do not distort the patient, and to aid the patient leg to the table and recheck at the malleoli to
to lie in a straight line. Then the hips and knees see if they are even and if the apparent leg
are extended to the table in the midline. The lengthening is corrected. In addition, the patient
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examiner stands at the foot of the table and may be instructed in correcting this himself as
grasps the patient's heels, one in each hand. part of his postural exercise program. This can
The patient's hips are slightly flexed with the be done when supine, standing, or sitting as
knees extended, and his heels are abducted shown in Figure 6.
from 12-1 6 in (30-40 cm). An upward thrust is If the legs appear to be even at the malleoli
made as if to thrust the heads of the femurs into but bilateral anterior dysfunction of the sacroiliac
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

the hip sockets. After this they are adducted and joint is suspected, an attempt should be made to
lowered to the table with an equal amount of mild
manual traction on each, the medial malleoli
being held together in the midline and care being
taken to ensure that the patient is lying straight.
This is similar to a method described by Beal,4
but the addition of some mild traction after the
upward thrust seems to increase the apparent
difference in leg length. If the leg on the painful
Journal of Orthopaedic & Sports Physical Therapy®

side appears to be from 3/8-5/8 in (1-1.5 cm)

longer at the malleoli or at the heels than the
normal one, it may indicate anterior dysfunction
of the sacroiliac joint with apparent leg lengthen-
ing on that side."" When evaluating the com-
parative leg length at the malleoli, any difference Fig. 4. Method of mobilization to correct anterior dysfunction
of the sacroiliac joint and reduce apparent lengthening of the
will be more obvious if you place a thumb be-
leg. (Courtesy of The D.O.)
neath each medial malleolus when holding them
together.
"In the case of a suspected apparent
lengthening of the right leg, confirmation is made
by mobilization in the following manner: with the
patient supine on the examining table, the ther-
apist stands at the patient's right side and places
his right hand between the patient's legs under
the right ischial tuberosity and buttock. Then he
places the heel of his left hand on the anterior-
superior spine of the ilium with the fingers point-
ing laterally and rotates the right innominate
bone strongly back and upward. Then he reex-
amines the patient's legs to see if the malleoli Fig. 5 . Alternate method of treatment, viewed from above.
are even."" (Courtesy of The D.O.)
 26 DONTIGNY Vol. 1 , No. 1

A Complication of Anterior Dysfunction

If a patient has pain in the low back on the
ipsilateral side during passive straight leg rais-
ing, when a posterior torsion strain is placed on
the sacroiliac joint, it is not necessarily indicative
of a posterior sprain or posterior dysfunction as
has been proposed.27.28 If ipsilateral pain is in-
creased with flexion of the innominate on the
sacrum, with the patient supine, grasp the leg
above the ankle and put traction on the leg in
the long axis. Pull firmly and then recheck the
malleoli. The involved leg will now appear to be
Fig. 6. Methods of self-correction. A, correction standing or equal to or longer than the uninvolved leg. Now
supine, pull the knee into the ipsilateral axilla. Alternate
when the innominate is flexed on the sacrum
several times. 6,with one foot on a table or bench, lean
toward the knee stretching it into the axilla. Alternate. C, there should be no pain and the leg will appear
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when sitting, pull one knee into the axilla and sit with it there to shorten with correction. The direction of the
for a few minutes. Alternate. Repeat these many times during maneuvers that relieve the pain and the resultant
the day and always make a correction just before bed that
changes in apparent leg length give us important
will relieve the strain on the involved ligaments for several
hours.
clues as to the nature of the dysfunction. Appar-
ently the innominate rotates slightly anteriorly on
the sacrum and then, perhaps after prolonged
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

sitting, slips cephaladly complicating the original

rotate each innominate bone posteriorly on the dysfunction. This, then, requires two separate
sacrum. One innominate bone is rotated poste- maneuvers to correct-traction on the leg to
riorly, and then the patient is reexamined to see correct the vertical slip and then flexion to cor-
if the corresponding malleolus now appears to rect the anterior dysfunction. Posterior torsion
be higher than the uncorrected one, indicating sprain or posterior dysfunction may exist by it-
correction into a shortened position. He then tips self, but it is not common.
the uncorrected side posteriorly, and if a correc-
tion has been made, the malleoli will appear to
MEASUREMENTS
Journal of Orthopaedic & Sports Physical Therapy®

be even. Frequently one side will be much more

difficult to correct than the other, and for this Measuring the leg length in the conventional
reason an attempt at correction should be made manner from beneath the anterior-superior spine
on each side. When the less involved side is of the ilium to below the medial malleolus prob-
corrected, the difficulty in correcting the other ably will not demonstrate any appreciable differ-
side is lessened. Correction not only confirms ence between the side with the apparent
the supposition of anterior dysfunction of the lengthening and the normal side. Menne1Iz7sug-
sacroiliac joint, but has the advantage of reliev- gested that while the patient is standing both
ing the pain in the lower part of the back when legs be measured from the anterior-superior iliac
apparent leg lengthening is present. One or two spines to the floor and from the posterior-supe-
sessions of treatment may be enough to correct rior iliac spines to the floor. This will make ap-
the condition if it results from recent trauma; but parent any rotation of the pelvis on one side or
if the patient has suffered from recurrent back- the other. The apparent increase in leg length
ache and displays an obvious weakness of the that occurs with the anterior dysfunction of the
anterior pelvic support, the malleoli must be sacroiliac joint may make the crest of the ilium
checked at each treatment session and the ap- on the involved side higher than the crest on the
parent lengthening corrected as necessary to uninvolved side even though the anterior-supe-
relieve the strain on the involved ligaments and rior spine of the ilium on the involved side may
allow them to recover." It is frequently neces- be even with or slightly lower than the other.
sary to flex each innominate on the sacrum al- When this occurs, the posterior-superior spine
ternately, two or three times, until no more ap- will measure slightly higher on the involved
parent shortening takes place. side.''
 Summer 1979 DYSFUNCTION OF SACROILIAC JOINT

If each measurement on one side is longer

than each measurement on the other side, an
actual difference in leg length is probable. In the
presence of even moderate pain in the lower part
of the back, it is not possible to determine a
difference in actual leg length without first mo-
bilizing the innominate bone upward and poste-
riorly to see if apparent leg lengthening is pres-
ent. Bailey and Beckwith3 stated that "often a
difference of a centimeter or more in the heights
of crests will be wiped out following the correc-
tion of a pelvic lesion." The posterior-superior
spines also will measure lower after mobilization
treatment than before. With the patient prone,
careful measurements from the posterior-supe- Fig. 7 . Tracings of roentgenograms. Doffed line represents
pelvis before correction of anterior dysfunction of the sacro-
rior spines to the medial malleoli before and after
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iliac joint on the left. Solid line shows pelvis after correction.
mobilization will demonstrate shortening of from Tracings were overlaid to demonstrate movement that oc-
in (1 -1 .5cm)." curred on correction. (Courtesy of The D.O.)
In order to determine whether the high crest is
caused by a difference in leg length causing a
pelvic obliquity or by pelvic obliquity causing an ulum on the left was higher than the one on the
apparent difference in leg length, the level of the right without a corresponding increase in height
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

iliac crests should be checked first with the of the iliac crest. This suggests rotary movement
rather than a lateral tilt. The right deviation of the
patient standing and then with the patient sitting
on a firm surface. If one crest is still high with pubic symphysis moved medially with some lat-
the patient sitting, then it is probable that pelvic eral movement of the right ilium on the sacrum.
obliquity caused the apparent discrepancy in leg Finally, there was a definite movement down-
length. Crest height during sitting frequently is ward of the left ilium on the sacrum, seen at the
equalized after proper corrective manipulation." posterior-superior spine and greater sciatic
notch in relation to the first sacral foramen.I8
Roentgenograms were made of a second
DEMONSTRATIONS
Journal of Orthopaedic & Sports Physical Therapy®

young man with a suspected bilateral anterior

Roentgenograms were taken before and after dysfunction of the sacroiliac joints, before and
mobilization of an apparent leg lengthening of after flexing each innominate on the sacrum.
the left lower extremity of a 21-year-old man. These were done with the patient standing,
The patient was positigned supine on the roent- weight evenly distributed on both feet and the
gen ray table and both knees were flexed to his knees fully extended. A roentgenogram (Fig. 8)
chest to flatten the lumbar spine, minimize pelvic was made before correction, a second (Fig. 9)
obliquity, and assure the symmetry of the gluteal after flexion of the right innominate on the sac-
muscles. The patient's feet were then extended rum, and a third (Fig. 10) after flexion of the left
to a tape mark on the table while the hips and innominate on the sacrum. Figure 9 shows a
knees were left comfortably flexed, and a roent- slight flattening of the sacral plateau. Figure 1 0
genogram was made. Then the left innominate shows a definite flattening of the sacral plateau
bone was moved posteriorly on the sacrum and with a resultant, widening of the L5-S1 inter-
a second roentgenogram was taken with the space. It also shows a definite movement down-
patient in the same position. Tracings of the ward of the posterior superior spines in relation-
roentgenograms (Fig. 7) demonstrate the move- ship to the first sacral foramina.
ment that took place. The pelvis was flattened.
The sacral plateau was flattened, indicating flat- ASSOCIATED CONDITIONS
tening of the lumbosacral angle. Slight reduction Referred Pain
of the width of the pelvis suggests that the in-
nominate bones may have been wedged apart Pain most commonly found with anterior dys-
by the sacrum prior to mobilization. The acetab- function is "tenderness over the symphysis
 28 DONTIGNY Vol. 1 , No. 1
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Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Fig. 8. Roentgenogram of a suspected bilateral anterior dysfunction before correction.

Journal of Orthopaedic & Sports Physical Therapy®

pubis on the side affected, tenderness over the Although sciatic nerve pain is frequently as-
iliosacral articulation on the side affected, and sociated with anterior dysfunction of the sacro-
tenderness along the crest of the ilium where the iliac joint it is probably not a referred pain. Dan-
abdominal muscles are attached.26 Norman and forth and Wilsoni4 determined that the sacroiliac
May32found that "a sacroiliac lesion produces joint did not act directly to cause sciatic nerve
pain over the gluteal region, the posterior thigh, pain because "there is no canal nor semblance
the posterolateral calf and the lateral border of of a canal which holds the nerves against the
the foot." joint." It seems reasonable that the nerve trunk
Occasionally there will be associated pain in could be irritated directly by the undue stretching
the abdomen at Baer's sacroiliac point, which of the sciatic nerve associated with the apparent
has been described as being 2 inches from the lengthening of the leg found with anterior joint
umbilicus on a line drawn from the umbilicus to d y s f u n ~ t i o n . 'In
~ a person with an anterior dys-
.the anterior-superior spine.27 Torsion strain on function the nerve is stretched even more with
the sacroiliac joint can modify tenderness at this every step during normal gait; when flexion of
point. Norman33also found abdominal pain as- the hip is followed by extension of the knee and
sociated with sacroiliac dysfunction. Wilson42 dorsiflexion of the ankle, which is merely a ver-
called attention to the fact that "unusual radia- tical variation of Lasegue's test. Cailliet6explains
tion of pain from the lower three lumbar vertebral that "stretching the nerve stretches the dural
joints has led to the unnecessary removal of sheath of the nerve and thereby impairs its blood
pelvic organs in the female and to coccygec- supply, the ischemia of the nerve causing the
tomy." pain."
 Summer 1 9 79 DYSFUNCTION OF SACROILIAC JOINT 29
Pain on Sitting found a separation. Actually, they can go either
way, depending on whether the patient is sitting
If wedging at the sacroiliac joints has already with the pelvis slightly extended with anterior
slightly spread the innominate bones, any pres- joint torsion or with the pelvis slightly flexed with
sure that might increase the spreading and the posterior joint torsion.
resultant ligamentous stretch probably would be There is little or no pain on sitting if the patient
p a i n f ~ l . 'Grant2'
~ stated that "In the standing will sit 4 or 5 in (10-1 2 cm) from the back of the
posture, the acetabula and the sidewalls of the chair and then slump, sitting on the back of the
pelvis tend to be forced together, but the pubic pelvis rather than on the bottom of the pelvis.
bones, acting as struts, prevent this from hap- Nachemson's studies3' have found an increase
pening. In the sitting posture the ischial tuber- in intradiscal pressure on sitting but the author
osities tend to be forced apart." believes that it is probably not related to pain
Note in Figure 3 that when the innominates produced by the sacroiliac joint on sitting, be-
are rotated, the ischial tuberosities are behind cause while sitting in some degree of extension
their normal position. Weight-bearing on them may be painful, sitting in flexion is usually not,
during sitting increases the anterior rotational especially after proper mobilization.
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strain on the ligaments, tending to spread the

innominates and increasing the distance be- Pain on Increase of lntraabdominal Pressure
tween the posterior superior spines. Menne1I2'
found an approximation of the posterior superior Anything such as coughing or sneezing or
spines on sitting from prone, while Colachisi0 constipation which increases intraabdominal
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

Fig. 9. Bilateral anterior dysfunction after flexion of the right innominate on the sacrum.
 30 DONTIGNY Vol. 1 , No. 1
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Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

Fig. 10. Bilateral anterior dysfunction after flexion of the left innominate on the sacrum. Note widening of L5-S1 interspace and
movement downward of the posterior superior spines in relationship to the first sacral foramina.

pressure has a tendency to spread the innomi- step may also be shortened to protect a painful
nates and may precipitate pain or increase ex- sciatic nerve.
isting pain. Climbing stairs is frequently painful. Weakness
The increase in intradiscal pressure that ac- in the anterior pelvic support allows the innomi-
companies an increase in intraabdominal pres- nate to rotate downward on the sacrum as the
sure may not be associated with the increase in hip flexors, pulling from the iliac fossa, raise the
pain because if you stabilize the pelvis by man- weight of the leg upward during swing phase.
ually compressing the ilia you can usually sneeze Chronic weakness in the anterior pelvic sup-
or cough in relative comfort and this maneuver port, especially accompanying obesity makes
is not likely to affect intradiscal pressure one the hip flexors less efficient by approximating
way or another. the origin to the insertion. The patients will fre-
quently walk with their hips in external rotation
Changes in Gait using their hip adductors to assist with flexion.
This can cause a valgus deformity at the knees.
Charles Ducroquet was reported by his sons
to have remarked that certain painful reactions Pain During Pregnancy
of the sacroiliac joints lead to a shortening of the
step. His sons added this comment: "The pain Anterior dysfunction is particularly common
of torsion of the sacrum on the iliac wing, in during pregnancy as weight on the anterior pel-
reality, limits the pelvis ~ t e p . " 'The
~ length of the vis causes an anterior torsion strain on the sa-
 Summer 1979 DYSFUNCTION OF SACROILIAC JOINT 31
croiliac joints. Relief can be obtained by frequent not anesthetic. Cold, while anesthetic, is not
flexion of the knee to the axilla and by instructing particularly analgesic. Whether you use wet or
the patient to lean slightly backwards from the dry heat is unimportant. While wet heat is more
hips when standing so that most of the trunk penetrating than dry heat at the same tempera-
weight is on the posterior pelvis. ture, dry heat can be tolerated at higher temper-
atures. At the hiqhest tolerated temperatures,
Instability Before the Menstrual Cycle heat penetration is about equal.' When cold is
used, there is little point in applying it before the
Women are particularly susceptible to anterior electric stimulation and massage as this will
dysfunction about a week or 10 days before the warm the area which has been cooled. The ef-
menstrual cycle. The presence of relaxin in the fects of the cold will last longer when applied
body at that time precipitates a hormonal liga- after the other modalities. The cold should be
mentous laxity that renders the pelvic ligaments applied over a dry towel or a warm damp towel
more prone to minor injury. The relaxin is reab- to avoid an initial shock to the patient. Relaxation
sorbed during the menstrual cycle and, if the is enhanced if heat is applied to another part of
innominate is kept in its normal position on the the body while the cold packs are in place to
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sacrum at this time, the pelvic ligaments regain maintain core temperat~re.~.31 1 7 3

their normal stability. It has been our observation The use of continuous heat prior to mobiliza-
that if the dysfunction is not corrected, the insta- tion is contraindicated. The local increase in
bility may continue until the next menstrual cycle. circulation from the prolonged application of
heat causes edema which frequently prevents
MANAGEMENT mobilization correction.
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Evaluation and mobilization must be done be-

fore the application of any modalities. It is essen- Traction
tial that the patient and the therapist be acutely Pelvic traction does not seem to be helpful in
aware of any movement which initiates or elim- the treatment of anterior dysfunction of the sa-
inates, aggravates or alleviates pain. You do not croiliac joint. However, wrapping the pelvic trac-
mobilize into pain. Everything must be done tion belt snugly around the pelvis does seem to
within the limits of pain. help prevent recurrence by preventing the in-
nominate bones from spreading and thus limiting
Rest in Bed
Journal of Orthopaedic & Sports Physical Therapy®

the amount of wedging possible. The overlap-

During the acute phase, rest in bed is very ping flaps from a Scultetus binder with a tail
important. When lying on the side, place a pillow stitched to it posteriorly make an excellent pelvic
between the knees. When lying supine, a pillow traction belt, which is comfortable and com-
placed under the low edge of the buttocks is pletely adjustable."
extremely helpful. This tends to keep a slight Leg traction applied to a patient with apparent
pressure in posterior rotation and frequently re- lengthening of the leg serves only to increase
lieves all pain so that the patient can rest much the deformity, pulling on the longer involved side
better. Making the patient comfortable frequently when shortening is necessary."
makes additional medication unnecessary. Intermittent traction is effective in separating
the vertebrae which may be necessary to relieve
Modalities pressure on a disc.g In the presence of pain from
a facet syndrome intermittent traction may sep-
For the relief of chronic pain, we find that arate the vertebrae enough to relieve the binding
mobilization followed by heat, electric stimulation and allow normal realignment.
(with or without ultrasound), and massage is
effective. The currents used for transcutaneous Exercise
electrical nerve stimulation5.25. 35. 37 are particu-
larly helpful in relieving back pain and their ef- Proper exercise is absolutely essential to re-
fects seem to last much longer if used after lieve pain and to prevent recurrence of joint
mobilization correction. If the pain is acute, we dysfunction. The patient must be instructed thor-
follow mobilization with electric stimulation, mas- oughly in what to do, how to do it, and why it
sage, and an ice pack. Heat, while analgesic, is must be done. The 1st day, demonstrate to the
 32 DONTIGNY Vol. 1 , No. 7

patient what must be done. The 2nd day, have program. It should be put on after treatment
the patient demonstrate what is being done so when the joint dysfunction has been corrected.
corrections may be made if necessary. A good sacroiliac support or even a simple trou-
Correction of anterior dysfunction by flexion ser belt worn just below the anterior-superior
of the innominate on the sacrum is done by iliac spines will serve to stabilize the pelvis, al-
having the patient flex his knee to the axilla as though a good lumbosacral support of fabric with
shown in Figure 6. This must be done two or at least two paravertebral metal stays and ad-
three times on each side, alternating sides. This justable side lacing will be more effective. This
should be done several times a day and espe- provides stability in both pelvic and lumbar flex-
cially upon going to bed to relieve the dysfunc- ion. To be most effective, the support must be
tion and allow the ligaments several hours during put on properly. The patient should lie supine on
the night to recover. This minimizes getting up the opened support and flex his knees to his
with a stiff sore back in the morning. Flexion of axillae as described. This also minimizes the
the knee to the chest flexes the pelvis and the sacral angle, flattens the lumbar lordosis, and
spine and does not provide adequate correction. lessens pelvic obliquity. He then places his feet
Flexion of the knee to the axilla flexes the innom- flat on the table, with the hips and knees flexed,
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inate on the spine. and the support is fastened and adjusted snugly,
In order to prevent recurrence of back pain, especially around the pelvis, where it tends to
the patient must learn to use his abdominal mus- relieve the strain on the pelvic ligaments by
cles constantly to support the anterior pelvis. It preventing spreading and locking. In this position
is especially important to hold the abdominal the support will help to maintain the postural
muscles in tightly and to pinch the buttocks corrections that have been made and to prevent
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

tightly together to stabilize the pelvis when lean- recurrence of the anterior dysfunction. If the
ing forward, whether to shave, make a bed, work support is put on when dysfunction is not cor-
over a counter, or to lift something. rected, it not only will fail to correct the joint
The abdominal muscles should be dysfunction, but may increase pain by increasing
strengthened to provide sufficient pelvic support pressures on the pelvic joints in that position."
by doing a partial sit-up, with the hips and knees
bent. Leg-raising exercises should never be Heel Lifts
used as an abdominal strengthening exercise.
Aside from the fact that the abdominal muscles A heel lift may be prescribed for a patient with
don't raise the legs, in the absence of a strong one leg shorter than the other, but only after
Journal of Orthopaedic & Sports Physical Therapy®

stabilizing force from the abdominals on the an- careful measurements indicate an actual bony
terior pelvis, the pull of the iliacus from the iliac discrepancy. A heel lift should not be considered
fossa causes a strong anterior rotational force of if apparent differences in leg length can be cor-
the innominate bones on the sacrum. All leg rected quickly by a painless mobilization maneu-
raising exercises should be ~ontraindicated.~ ver.
The downward inclination of the pelvis and Heel lift therapy is frequently used to correct
increased difficulty in doing a pelvic tilt which a high iliac crest in patients with idiopathic sco-
occurs with anterior joint dysfunction gives the liosis. These patients should also be evaluated
impression of tightness in the hip flexors. Eval- for anterior dysfunction of the sacroiliac joint
uation of hip flexor tightness should be made before recommending a heel lift.
following correction. lfstretching of the hip flex-
Transcutaneous Nerve Stimulators
ors are necessary, it should be done with care
as it puts an anterior rotation strain on the sacro- While electric stimulation is extremely helpful
iliac joint, which may precipitate or increase an in the acute phase, after the patient has been
anterior dysfunction of the sacroiliac joint. established on an effective home program, it is
seldom necessary. It is occasionally helpful in
Supports cases of obesity and chronic joint instability.
Occasionally it may be necessary to use a FUNCTION
support, especially with long-standing obesity,
excessive abdominal weakness, or chronic joint The sacroiliacjoint is a strong joint structurally
instability. Its use should supplement but not and in recent years it has been regarded as a
replace a good prophylactic postural training "misconception" that "the sacroiliac joint was
 Summer 19 79 DYSFUNCTION OF SACROILIAC JOINT 33
susceptible to strain and subluxation from trivial tected from sinking into the pelvis and the ilia
from rotating posteriorly on the sacrum. Unfor-
Gray's Anatomy2' states that the function of tunately, the relatively thin sheath of anterior
the sacroiliac joints is to lessen concussion in sacroiliac ligaments does not offer the same
rapid changes of distribution of body weight in protection from movement and injury in the op-
each of two directions. In doing so it undergoes posite direction. Anterior rotation of the innomi-
some rotation through a transverse axis. One nate bones on the sacrum not only tends to
component of the force is expended in driving loosen the fibers of the strong posterior sacroil-
the sacrum downward and backward and is re- iac ligaments, but spreads the ilia on the sacrum
sisted by the wedge shape of the sacrum and causing them to wedge or bind. Fixation of the
the sacroiliac and iliolumbar ligaments. The sec- sacroiliac joint prevents function, and forces pre-
ond component of force produces a rotatory viously expended in the joint are transmitted to
movement by which the superior end of the the intervertebral disk. This may be a significant
sacral articulation is tilted down and the inferior factor in herniation of the disk."l8
part up and is resisted by the wedge form and On heel strike, the force created travels up the
the sacroiliac, sacrotuberous, and sacrospinous leg and is absorbed in the sacroiliac joint as the
ligaments. The joint acts as a shock absorber. If innominate is caused to rotate slightly posteriorly
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an outside force creates a minor displacement on the sacrum, stretching the heavy posterior
of the articular surfaces of the sacroiliac joint, sacroiliac ligaments which in turn cause the in-
the displacement is quickly corrected by the nominate to return to its normal resting position.
strong pull of the surrounding ligaments aided If the function of the sacroiliac joint is blocked,
by the wedge shape of the sacrum. then this posterior force, instead of being ab-
O ' D ~ n o g h u estated
~ ~ that the sacrum is the sorbed, causes the entire pelvic ring to be
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

keystone of the pelvic arch. Grant2' described torqued around the L5-S1 disk. It seems highly
the rotary movement of the sacrum and stated: probable that this is the cause of the torsion
"The articular surfaces of the sacrum are farther changes that occur in the disk before herniation.
apart in front than behind: so, the sacrum be- Pain in the low back is also a frequent accom-
haves not as a keystone, but as the reverse of a panying affliction of patients with hip disease.
keystone, and tends therefore to sink forwards The lateral thigh muscles that originate from the
into the pelvis. As it does so, the posterior liga- iliac crest posterior to the line of gravity and lie
ments become taut and draw the ilia closer to- posterior to the greater trochanter are in a rela-
gether with the result that the interlocking ridge tively shortened position during normal standing
Journal of Orthopaedic & Sports Physical Therapy®

and furrow engage more closely. Here is an posture. In the lordotic posture and during an-
automatic locking device." terior dysfunction of the sacroiliac joint the in-
This would seem to bear out the early obser- nominate rotates around the acetabula so that
vations of Cunningham,12 of which Dwight said the origin of those muscles on the iliac crest
that "As the sacrum narrows towards its dorsal moves anteriorly and the greater trochanter
surface, and is really suspended from the iliac moves posteriorly and the muscles which laid
bones by the posterior sacroiliac ligaments, it posterior to the trochanter now lie over the top
cannot be considered as the keystone of an of the trochanter stretching those involved mus-
arch." In its normal functioning state, the sacro- cles. As those muscles are stretched and func-
iliac joint is a nonweight bearing joint. tioning from an unnatural position they also serve
S~hunke noted
~ ~ that supernumerary sacroil- to pull the head of the femur more tightly into the
iac facets are common and stated that "only acetabulum disposing it to increased wear from
slight motion would be required to dislocate them the increased pressure. This is probably exac-
or other slight irregularities upon the articular erbated by an increase in apparent leg length
surfaces. Tension of the interosseous ligaments and increased trauma to the head of the femur
would tend to keep such prominences dislocated because of the jarring effect created on heel
and resist the separation necessary for their strike with the nonfunctioning sacroiliac joint.
relocation, though they might be made to 'snap' Individual anatomical variations and variations in
back into position by more or less strenuous gait are also contributing factors.
mobilization."
Trotter4' found that accessory sacroiliac artic- COMMENTS
ulations occur in man in varying percentages. Before the work of Danforth and Wilson14 in
"It would seem that the sacrum is well pro- 1925, sacroiliac dysfunction was frequently
 34 DONITIGNY Vol. 1 , No. 1

found and associated with sciatic pain, but since surgical fusion. If fusion is considered it would
no anatomical relationship was found, the diag- seem that the joint should be fused in a corrected
nosis was assumed incorrect. When Mixter and position. If it is not corrected before fusion, a
Barr2' described the herniated intervertebral torsion strain is built into the pubic symphysis
disk in 1934 it was then assumed that sciatic and further instability is likely to occur in that
pain was a result of a herniated disk. Since about area."
60-70% of people with pain in the low back There is presently much too great a tendency
have some degree of sciatic nerve irritation, but to become method oriented in the treatment ap-
only about 5% of patients with pain in the low proach. Conservative therapists tend to stay with
back undergo surgery for herniated disk, this heat and massage not wanting to do more for
relationship is unlikely. The relationship between fear of hurting the patient, but perhaps not doing
sacroiliac dysfunction and sciatic pain exists, but enough to help the patient either. The acupunc-
is biomechanical in nature rather than strictly turists and those practicing shiatsu may not be
anatomical. using mobilization, or cold, or heat and massage
Of all cases with pain in the low back, referred when they are indicated. The manual therapists
to this department, just over 80% have anterior should similarly include any appropriate modality
Downloaded from www.jospt.org at on December 22, 2014. For personal use only. No other uses without permission.

dysfunction of the sacroiliac joint and of those, or procedure, even though it may extend the
about 55% were affected bilaterally. treatment time somewhat. Everyone should
Frequently radiographic evidence does not question the sequence of modalities and whether
correspond to clinical evidence. Cyriax13 com- they are appropriate. The key is proper evalua-
mented: "Everytime a patient is labelled 'cervical tion of the problem and then becoming problem
spondylosis,' 'lumbar arthritis' or 'degenerate oriented, adapting the methods to the problem
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

disc' it is highly probable that an error in empha- rather than the problem to the method.
sis has been made. Although this is what the
roentgenogram shows, a few months from now SUMMARY
when the patient has no symptoms he will still
have his osteophytes or his narrowed space." Pain in the low back is commonly precipitated
Unfortunately, the traditional approach to mo- when an individual leans forward to perform
bilization of the sacroiliac joint has been an at- some task and fails to support his anterior pelvis
tempt to correct a high iliac crest by extending with his abdominal muscles. The resultant ante-
the innominate on the sacrum. This is usually rior rotation of the innominate(.$ on the sacrum
Journal of Orthopaedic & Sports Physical Therapy®

done with the patient side-lying and with the may result in fixation, acute pain and an apparent
operator behind the patient pulling backward on lengthening of the leg(s). It is more common
the shoulder and thrusting the innominate for- bilaterally, but frequently occurs on just one
ward and downward on the sacrum. This is done side.
in the mistaken belief that a high crest is caused The apparent lengthening of the leg(@ is a
by an upward dysfunction of the joint when, result of the alteration of relationship between
actually, the high crest is caused by anterior the sacroiliac joints and the acetabulae. The
dysfunction and concurrent apparent lengthen- lengthening of the leg(s) results in a lengthening
ing of the leg. This maneuver could serve to of the sciatic nerve which frequently causes a
open the joint slightly at which time the taut sciatic neuritis.
sacroiliac ligaments would rebound the innomi- Flexion of the innominate(s) on the sacrum by
nate into its proper position, usually with a dis- flexion of the knee to the ipsilateral axilla re-
concerting thud. If this method of mobilization in leases the fixation, relieves the pain, appears to
the wrong direction is continued for any period shorten the leg and takes the stretch off of the
of time, one of two things will happen: the joint sciatic nerve. Recurrence is prevented by sup-
will be jammed much more tightly, or it will be- porting the anterior pelvis with the abdominal
come unstable requiring frequent adjustment muscles especially when leaning forward. The
usually at great cost and inconvenience to the corrective maneuver is safe as it causes minimal
patient. flexion. extension, or rotation of the spine.
If at all possible, the shock absorber function Occasionally, after the innominate has rotated
of the sacroiliac joint should be maintained, how- anteriorly on the sacrum, it may also jam slightly
ever some researcher^"^^' have reported ex- vertically, complicating the original anterior dys-
cellent relief of pain in the unstable joint following function. This requires two maneuvers to correct;
 Summer 19 79 DYSFUNCTION OF SACROILIAC JOINT 35
manual traction on the leg in the long axis to Patient Care 10:22-55. 1976
17. DonTigny RL. Sheldon KW: Simultaneous Use of Heat and Cold
correct the vertical complication and then flexion in the Treatment of Muscle Spasm. Arch Phys Med 43:235-237.
of the innominate on the sacrum to correct the 1962
anterior dysfunction. Relief is usually immediate. 18. DonTigny RL: Evaluation. Manipulation and Management of An-
terior Dysfunction of the Sacroiliac Joint. DO 14:215-226. 1973
19. Ducroquet R, Ducroquet J. Ducroquet P: Walking and Limping.
The author thanks Dr. Clark Grimm and the Radiology Department
A Study of Normal and Pathological Walking. Philadelphia, JB
of Northern Montana Hospital who provided the roentgenograms and
Lippincott Co.. 1968
to the American Osteopathic Association and The D.O. for their kind
20. Grant JCB: A Method of Anatomy. Descriptive and Deductive.
permission to reprint illustrations and quotations from an original
Sixth Edition. Baltimore. Williams 8 Wilkins Co.. 1958
article.
21. Gray H: Anatomy of the Human Body, Twenty-eighth Edition.
Edited by CM Goss. Philadelphia, Lea 8 Febiger, 1966
REFERENCES
Downloaded from www.jospt.org at on December 22, 2014. For personal use only. No other uses without permission.

22. Hines TF: Posture. Therapeutic Exercise. Second Edition. Edited

by S Licht and EW Johnson. New Haven, Elizabeth Licht. 1965
1. Abramson Dl. Tuck S, Lee SW, et al: Comparison of Wet and Dry 23. Kendall HO, Kendall FP, Boynton DA: Posture and Pain. Balti-
Heat in Raising Temperature of Tissues. Arch Phys Med 48: more, Williams 8 Wilkins Co.. 1952
654-661. 1967. 24. Larson NJ: Sacroiliac and Postural Changes from Anatomic Short
2. Arnell P. Beattie S: Heat and Cold in the Treatment of Hyperto- Lower Extremity. JAOA 40:88-89, 1940
nicity. J Can Phys Ther Assoc 24:61-67. 1972 25. Loeser JD, Black RG. Christman A: Relief of Pain by Transcuta-
3. Bailey HW, Beckwith CG: Short Leg and Spinal Anomalies. Their neous Stimulation. J Neurosurg 42:308-314, 1975
Incidence and Effects on Spinal Mechanics. JAOA 36:319-327, 26. McConnell CP. Teall CC: The Practice of Osteopathy, Third
Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

1937 Edition. Kirksville. Mo., Journal Printing Co., 1906

4. Beal MC: A Review of the Short-Leg Problem. JAOA 50:109- 27. Mennell JB: The Science and Art of Joint Manipulation. Vol 2,
121, 1950 The Spinal Column. Philadelphia. Blakiston Co.. 1952
5. Burton C. Maurer DD: Pain Suppression by Transcutaneous 28. Mennell JM: Back Pain. Diagnosis and Treatment Using Manip-
Electronic Stimulation. IEEE Transactions on Biomedical Engi- ulative Techniques. Boston, Little. Brown 8 Co.. 1960
neering, Vol. BME, no. 2, March 1974, pp 81 -88 29. Mixter WJ and Barr JS: Rupture of the lnte~ertebralDisc with
6. Cailliet R: Neck and Arm Pain. Philadelphia. FA Davis Co. 1964. Involvement of the Spinal Canal. N Engl J Med 21 1:210. 1934
P 46 30. Nachemson A, Morris JM: In Vivo Measurements of lntradiscal
7. Cailliet R: Low Back Pain Syndrome. Second Edition. Philadel- Pressure. J Bone Joint Surg 46A:1077, 1964
phia. FA Davis Co., 1968 31. Newton MJ. Lehmkuhl D: Muscle Spindle Response to Body
8. Chamberlain, WE: The Symphysis Pubis in the Roentgen Exam- Heating and Cooling. J Am Phys Ther Assoc 45:91-105, 1965
ination of the Sacroiliac Joint. Am J Roentgen01 Radium Ther 32. Norman GF, May A: Sacroiliac Conditions Simulating Interverte-
Journal of Orthopaedic & Sports Physical Therapy®

Nucl Med 24:621-625, 1930 bra1 Disc Syndrome. West J Surg Obstet Gynecol 461-622.
9. Colachis SC. Jr. Strohm BR: Effects of Intermittent Traction on 1956
Separation of Lumbar Vertebrae. Arch Phys Med 50:251-258, 33. Norman GF: Sacroiliac Disease and its Relationship to Lower
1969 Abdominal Pain. Am J Surg 1 16:54-56. 1968
10. Colachis. SC Jr, Worden RE, Bechtol CO, et al: Movement of the 34. O'Donoghue, DH: Treatment of Injuries to Athletes. Philadelphia.
Sacroiliac Joint in the Adult Male: A Preliminary Report. Arch WB Saunders Co.. 1962
Phys Med 44:490-498, 1963 35. Picaza JA. Cannon BW, Hunter SE, et al: Pain Suppression by
11. Coventry MB, Tapper EM: Pelvic Instability. J Bone Joint Surg , Peripheral Nerve Stimulation. Surg Neurol 4:105-114, 1975
54-A:83-101. 1972 36. Schunke GB: The Anatomy and Development of the Sacro-Iliac
12. Cunningham DJ, cited by Dwight T, et al: Human Anatomy, Joint in Man. Anat Rec 72:313-331. 1938
Including Structure and Development and Practical Considera- 37. Shealy CN, Maurer D: Transcutaneous Nerve Stimulation for
tions. Edited by GA Piersol. Philadelphia. JB Lippincott Co.. Control of Pain. Surg Neurol 2:45-47, 1974
1907, p 346 38. Smith-Petersen MN: Discussion of Reference 14; published in
13. Cyriax J: Manipulation-by Laymen or Physiotherapists? J Can Reference 14
Physiol Assoc 23:236-238. 1971 39. Smith-Petersen MN: Arthrodesis of the Sacroiliac Joint. A New
14. Danforth MS. Wilson PD: The Anatomy of the Lumbo-Sacral Method of Approach. J Orthop Surg 3:400-405. 1938
Region in Relation to Sciatic Pain. J Bone Joint Surg 7:109- 40. Steindler A: Discussion of Reference 14; published in Reference
160. 1925 14
15. DeLorme TL: Exercise. Physical Medicine in General Practice. 41. Trotter M: A Common Anatomical Variation in the Sacro-Iliac
Third Edition. Edited by W Bierman and S Licht. New York. Paul Region. J Bone Joint Surg 22:293-299. 1940
B. Hoeber, Inc. 1952 42. Wilson JC. Jr: Low Back Pain and Sciatica. A Plea for Better
16. Diagnosing Back Pain: Take the Systematic Route to Causes. Care of the Patient. JAMA 200:705-712. 1967
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Copyright © 1979 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®