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Sacroiliac Joint Dysfunction in Athletes

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 Sacroiliac Joint Dysfunction in Athletes
P. Gunnar Brolinson, DO, FAOASM, FAAFP*,
Albert J. Kozar, DO, and Greg Cibor, DO
Address
*Edward Via Virginia College of Osteopathic Medicine,
Virginia Polytechnic Institute, 112 Merryman Center,
Blacksburg, VA 24061, USA.
E-mail: techdo@vt.edu
Current Sports Medicine Reports 2003, 2:47–56
Current Science Inc. ISSN 1537-890x
Copyright © 2003 by Current Science Inc.
The sacroiliac (SI) joint is a common source of low back pain
in the general population. Because it is the link between the
lower extremities and the spine, it sustains even higher loads
during athletic activity, predisposing athletes to a greater
probability of joint dysfunction and pain. The diagnosis and
treatment of SI joint dysfunction remains controversial, due to
complex anatomy and biomechanics, and a lack of universally
accepted nomenclature and terminology, consistently reliable
clinical tests and imaging studies, and consistently effective
treatments. This article clarifies these issues by presenting a
model of SI joint anatomy and function, a systematic approach
to the diagnosis of dysfunction, and a comprehensive
treatment plan.
Introduction
General history
The concept of the sacroiliac (SI) joint as a pain generator
is now well established. However, the evaluation and
treatment of sacroiliac joint dysfunction (SIJD) is contro-
versial. One issue is the broad categorization and termi-
nology utilized for the anatomic etiologies of the pain by
various health care practitioners. Controversy also exists
because of the complex anatomy and biomechanics of the
SI joint. There is no specific or salient historic issue, nor
single clinical examination technique, that is both sensi-
tive and specific for the diagnosis of SI dysfunction. To
date, imaging studies do not distinguish the asymptomatic
from symptomatic patient population, nor is there a gold
standard for treatment [1]. This article reviews a number
of studies and describes several different models put forth
regarding this difficult clinical entity. Further, it focuses on
the functional significance and similarities between mod-
els, and illustrates how a functional and principle-cen-
tered approach to the diagnosis and management of this
entity is essential in the athletic population. Although
individual physical examination testing procedures
appear to be unreliable, SI joint function and dysfunction
are best evaluated by applying a consistent palpatory and
functional examination technique, and adopting criteria
and nomenclature to develop a systematic approach to
this diagnostic dilemma. Accurate diagnosis is always
based on a combination of historic clues, along with find-
ings from static palpatory examination, segmental and
regional motion testing, overall functional biomechanical
examination, and appropriate diagnostic testing.
Athletes
Because of the unique nature of sport and the tremendous
demands that most sporting activities place on the spine
and pelvis, SIJD is well recognized by athletes and athletic
medical practitioners. In fact, some authors describe SI dys-
function as a common problem in elite athletes, but a clin-
ical entity that has been largely unstudied in the medical
literature [2]. One study evaluating members of the United
States Senior National Rowing Team indicated a prevalence
of SI dysfunction in 54.1% of team members, and more
common in sweep rowers (66%) than scullers (34%) [2].
SIJD may account for as much as 20% of low back pain
complaints in the general population [3,4].
Rowers are a group of athletes at risk for SI dysfunction
secondary to the biomechanical demands of rowing. The pel-
vis is relatively fixed while primarily transverse plane loads
are applied through the lumbosacral region. These muscle
action imbalances may disrupt the normal equilibrium of
muscle function around the pelvis and SI region. Similarly,
lumbosacral dysfunction has been described in cross country
skiers, due to the increased use of the asymmetrical V-skating
technique of high-performance skiers [5].
In addition to these specific examples, SIJD and the
resultant symptomatology can develop in any sport that
places significant biomechanical stress through the lumbar
spine and pelvis. This region serves as a force transfer link
between the lower extremities and torso, and as such is an
at-risk region for athletic injury.
Anatomy
Muscles, ligaments, and neural structures of the
low back
The anatomy of the SI joint must be viewed conceptually
as the entire lumbosacral region and pelvis. From an ana-
tomic perspective, this region is best viewed as a continu-
ous, ligamentous stocking based on the interconnections
of the various regional ligaments and fascial structures
48 Spine Conditions
Figure 1. Musculoligamentous sling of the lumbosacropelvic region.
The right side shows a part of the longitudinal muscle-tendon-fascia
sling. Below is the continuation between biceps femoris tendon and
sacrotuberous ligament, above a continuation of biceps femoris tendon
to the aponeurosis of the erector spinae. To show the right erector
spinae, a part of the thoracolumbar fascia has been removed. The left
side shows the sacroiliac joint (circle) and the cranial part of the oblique
dorsal muscle-fascia-tendon sling: latissimus dorsi muscle and thora-
columbar fascia. In this drawing, the left part of the thoracolumbar fascia
is tensed by the left latissimus dorsi and the right gluteus maximus.
outlined in the literature [6]. This ligamentous stocking is
the primary support of the osseous elements throughout
the lumbosacral pelvic region, and is anchored through
the thoracolumbar fascia of the back, and the hamstring-
sacrotuberous ligament complex of the pelvis (Fig. 1).
Throughout this ligamentous sling is a large sheet of fas-
cia that is the attachment site for multiple major muscle
groups of the spine, abdomen, and upper and lower
extremities. This fascia contains both a small-caliber,
unmyelinated C-fiber system, typical of nociceptors and
sympathetic axons, and a large-caliber fiber system with
encapsulated endings, typical of mechanoreception and
proprioreception. Force transfers through this region may
be under the proprioceptive control of neural elements
within this tissue. There are at least three separate sources
of these small-caliber primary afferent fibers throughout
the region [7••].
Aside from their role in the maintenance of normal tis-
sue tension and the propagation of possible prolonged
inflammatory responses, the interactive role of these neu-
ral elements is essential to the normal trophic activity of
this tissue. The stability and instability of this region is
dependent upon these muscular and ligamentous relation-
ships, and it is their breakdown and degeneration that can
lead to chronic pain syndromes. The continuous nature of
this ligamentous stocking gives the entire lumbosacral pel-
vic region a unitary function.
Development
During the 10th week of gestation, a cavity begins to form
in the area of the SI joint. This joint cavity fully develops
into the SI joint by the 8th month of gestation [8]. During
childhood, changes develop in the SI joint as the child
starts to walk, and intra-articular ridges and depressions
are developed secondary to an adaptation to gravitational
stress through the SI joint. Ultimately, the joint assumes an
L-shape in the adult, the intended purpose to provide
increased stability.
Adults
The adult SI joint demonstrates both a diarthrodial and a
synovial joint [9]. It becomes a well-defined L-shaped articu-
lation with an upper, long vertical pole and a short, lower
horizontal pole. Some have described this as an S- or a C-
shaped articulation [10]. There is significant variability of this
joint between individuals [8]; it can vary widely with respect
to size, shape, and surface contour, even within the same
individual. The horizontal pole articular compartment of the
SI joint always includes the second sacral segment, and rarely
includes L4, L5, or S4 segments [11]. In approximately 30%
of SI joints there is the potential for a vertical shearing effect
based on the angle of articulation [12,13].
Age-related changes
Moderate adaptive changes begin to occur on the iliac side
of the joint as early as the third decade, especially in men
[14]. There also appears to be an increase in size and num-
ber of elevations and depressions within the joint, which
most likely represent adaptations to increased gravitational
stress [8]. During the sixth and seventh decades there is
progressive advancement of these adaptive changes, and
thickening of the capsule; sometimes deep erosions expos-
ing the subchondral bone, resulting in degenerative joint
disease, is often noted. With increasing age, the capsule
becomes less cellular and relatively more collagenous, and
through the fifth and sixth decades becomes more thick-
ened and fibrous.
Of note, there do appear to be accessory articulations,
with an incidence of anywhere from 8% to 35%, that seem
most likely to develop in the posterior portion of the artic-
ulation near S2. These are possibly acquired as a result of
weight-bearing stress [8].
Biomechanics
History of the motion argument
There have been conflicting studies regarding the mobility
of the SI joints. For some time it was generally accepted
that there was motion early in life, but progressively less
motion as the degenerative changes of the joint took place,
and many investigators felt that the joints eventually fused.
Clinicians now feel that motion occurs throughout life [1].
Hypocrites first described pregnancy-related motions
of the SI joint in the fifth century BC. In 1689, Dimerbroch
 Sacroiliac Joint Dysfunction in Athletes • Brolinson et al.
described SI joint mobility in nonpregnant women. In
1864, Von Luschka was the first to categorize the SI joint as
a diarthrosis, suggesting the idea of motion. In 1905, Gold-
thwaith and Osgood described SI joint overuse and hyper-
mobility, leading to lumbar plexus irritation and ischialgia.
In 1909, Albee described it as synovial and mobile. Many
of these early studies were conducted on cadavers, and led
to conflicting reports in the literature.
In 1920, Halladay was the first to study unembalmed
corpses, and found asymmetrical SI joint movements. He
found that these movements also led to movements in the
pubic symphysis, and that back hyperextension leads to
displacement of the sacrum with respect to L5. Much of his
work was the basis for spinal mechanics, further developed
by the osteopathic profession. In 1921, Smith-Peterson
described an SI joint arthrodesis that was effective for ischi-
algia, and in 1934 Cyriax stated that the SI joint sublux-
ation can be measured by comparing leg lengths.
In the modern area, Bowen and Cassidy [8] were the
first to demonstrate that the SI joint is patent throughout
life, and in 1991 Ostgaard et al. [15] reported that SI joint
pain was one of the most common etiologies of low back
pain during pregnancy. In a number of studies throughout
the 1990s, Vleeming et al. [16,17] showed that the intra-
articular ridges and depressions that are found as we
progress through life are actually adaptations to the forces
on the SI joint. These adaptations increase the stability of
the joint, and imply its underlying mobility.
Actual validation of SI motion has been clearly estab-
lished in the modern era via clinical evidence and biome-
chanical studies. These studies note motion in both
prolonged and abrupt load patterns. Vleeming et al.
[18,19] showed that in vitro, loading tests showed SI joint
mobility into old age, and that prolonged loading caused
creep of ligaments. Buyruk et al. [20] used color Doppler
imaging to assess joint stiffness and motion in live subjects
in 1995, and the actual innervation of the joint was con-
firmed by Fortin et al. [21–23].
Biomechanical models of function have developed from
the first description of load transfer from the spine to the
lower extremities crossing through the SI joint, to the descrip-
tion of an integrated model of joint function [24••].
Motion
Axis of motion
The osteopathic profession espouses that there are at least
seven described axes of motion [25•]; however, these axes
should not be thought of as absolutes, but as functional
axes that occur pending the direction of forces applied
through the joint. These include a left and right oblique
axis, a vertical and anteroposterior (AP) axis, a vertical and
sagittal axis, and three horizontal axes. It should be noted
that none of these axes is rigid. The actual axis used
depends on the motion and the summation of forces that
move through the joint with a particular action.
49
Motion in gait
In the normal gait cycle, there are combined activities that
occur conversely in the right and left innominates, and
function in connection with the sacrum and spine (Fig. 2)
[26]. As one steps forward with the right foot, at heel strike
the right innominate rotates posterior and the left innomi-
nate rotates anterior. During this motion, the anterior sur-
face of the sacrum is rotated to the left and the superior
surface is level, while the spine is straight but rotated to the
left. Toward midstance, the right leg is straight and the
innominate is rotated anterior. The sacrum is rotated right
and side-bent left, while the lumbar spine is side-bent right
and rotated left. At left heel strike, the opposite sequence
will occur and the cycle is repeated.
Throughout this cycle there is a rotatory motion at the
pubic symphysis, which is essential to allow normal
motion through the SI joint. According to Greenman
[26,27], pubic symphysis dysfunction in walking is one of
the essential or leading causes of the development of SIJD.
In static stance, when one bends forward and the lumbar
spine regionally extends, the sacrum regionally flexes, with
the base moving forward and the apex moving posterior.
During this motion, both innominates go into a motion of
external rotation and out-flaring. This combination of
motion during forward bending is called nutation of the pel-
vis. The opposite occurs in extension, which is called coun-
ternutation. As the sacrum goes into extension with the base
moving posterior and the apex anterior, the innominate
components internally rotate and in-flare. This motion is
clearly demonstrated and illustrated by Kapandji [28].
Motion and respiration
The relationship of motion and respiration is very easy to
demonstrate, by placing one’s hand on the sacrum of a prone
patient. As the patient inhales the sacrum extends (the base
comes posterior and the apex moves anterior). This actually
involves a whole counternutation of the pelvis (sacral exten-
sion and innominate out-flare/external rotation). The axis of
motion in the SI joint is horizontal, and most likely roughly
through the second sacral segment [29].
Motion Dysfunction
Hypomobility
As previously noted, throughout later decades of life, the SI
joint becomes less mobile due to adaptive changes in both
the joint articulation and connective tissues. Some believe
that these changes are actually the result of hypermobility in
the joint and the body’s own response to this motion [11].
Hypomobility in general appears to be common in clinical
practice, in both acute low back and SI joint pain syndromes.
In the osteopathic profession, SIJD is broken down into
iliosacral and SI dysfunctions [25•,27]. This is primarily a
differentiation in terminology for identifying which part of
the anatomy plays the major role in motion restriction. Fur-
ther, the dysfunctions are named for their bony position of
50 Spine Conditions
ease. Somatic dysfunction implies impaired or altered func-
tion of the related components of the somatic (body frame-
work) system: skeletal, arthroidal, and myofascial structures
and related vascular, lymphatic, and neural elements. There
are three types of primary iliosacral dysfunction: 1) innomi-
nate shears, superior and inferior; 2) innominate rotations,
anterior and posterior; and 3) innominate in-flare and out-
flare. There are two main types of dysfunction: 1) sacral tor-
sions, flexion and extension; and 2) unilateral sacral lesions,
flexion and extension.
Torsions have both a right and left anterior and right
and left posterior types. These are diagnosed when rotation
is the primary component, although there is an additional
side-bending component as well. Unilateral lesions tend to
have a primary flexion or extension plus side-bending
component, as opposed to a rotatory component. A bilat-
erally flexed or extended sacrum is also possible, which is
often found in certain decompensated postures and during
pregnancy [25•,27,29].
Hypermobility
Gross SI joint instability is rare, but microinstability is a
relatively common component seen in patients with
recurrent SIJD. This microinstability often leads to
chronic pain syndromes and must be treated as part of
these complex pain presentations. Instability often occurs
as a result of the loss of the functional integrity of any of
the systems of the lumbosacral and pelvic region that pro-
vide stability. The myofascial or the osteoarticular and lig-
amentous components may be affected, as with chronic
spondylolisthesis. Understanding this concept is critical,
because it implies that a thorough evaluation of the
Figure 2. Sacroiliac joint motion during
walking. A, 1) and 2): At right heel strike. 1)
Right innominate has rotated in a posterior and
left innominate in an anterior direction. 2) Ante-
rior surface of sacrum is rotated to left and supe-
rior surface is level, while spine is straight but
rotated to the left. 3) and 4): At right mid-stance.
3) Right leg is straight and innominate is rotating
anterior. 4) Sacrum has rotated right and side-
bent left, while lumbar spine has side-bent right
and rotated left. B, 5) and 6): At left heel strike.
5) Left innominate begins anterior rotation; after
toe-off, right innominate begins posterior
rotation. 6) Sacrum is level but with anterior
surface rotated to the right. The spine, although
straight, is also rotated to the right, as is the
lower trunk. 7) and 8): At left leg stance. 7) Left
innominate is high and left leg straight. 8)
Sacrum has rotated to the left and side-bent
right, while lumbar spine has side-bent left and
rotated right.
lumbosacropelvic function must be carried out in the
evaluation for SIJD, regardless of the origin of pain.
Subluxation
Subluxation indicates gross instability of the SI joint and is
quite rare in the general athletic population. It is primarily
described in injuries resulting in significant energy input,
such as car and motorcycle accidents. Some evidence for
this phenomenon has been described in the orthopedic
and radiographic literature vis a vis joint arthrography with
use of contrast, indicating some form of traumatic disrup-
tion of the SI joint [30].
Role of Sacroiliac Joint Coupling Between the
Spine, Pelvis, Legs, and Arms
Biomechanics between the spine and pelvis
In 2001, Vleeming et al. [24••] described their integrated
model of joint dysfunction. This functional description
comes from extensive study of the SI joint over the past 10
to 15 years, and is the most studied and supported model
for SIJD. It integrates structure (form and anatomy), func-
tion (forces and motor control), and the mind (emotions
and awareness) on human performance. Integral to the
biomechanics of SI joint stability is the concept of a self-
locking mechanism. The SI joint is the only joint in the
body that has a flat joint surface that lies almost parallel
to the plane of maximal load. It’s ability to self-lock
occurs through two types of closure, form and force. Form
closure describes how specifically shaped, closely fit con-
tacts provide inherent stability independent of external
load. Force closure describes how external compression
 Sacroiliac Joint Dysfunction in Athletes • Brolinson et al. 51

Figure 3. The cross-like configuration demonstrating the force closure of the sacroiliac joint. The sacroiliac joint becomes stable on the basis of
dynamic force closure via the trunk, arm, and leg muscles that can compress it, as well as its structural orientation. The cross-like configuration
indicates treatment and prevention of low back pain with strengthening and coordination of trunk, arm, and leg muscles in torsion and
extension rather than flexion. The crossing musculature is noted. A, 1) Latissimus dorsi; 2) thoracolumbar fascia; 3) gluteus maximus;
4) iliotibeal tract. B, 5) Linea alba; 6) external abdominal obliques; 7) transverse abdominals; 8) piriformis; 9) rectus abdominis; 10) internal
abdominal obliques; 11) ilioinguinal ligament.

forces add additional stability. It had long been thought
that only the ligaments in this region provided that addi-
tional support. It is the fascia and muscles within the
region that provide significant self-bracing or self-locking
to the SI joint and its ligaments through their cross-like
anatomic configuration. Ventrally, this is formed by the
external abdominal obliques, linea alba, internal abdom-
inal obliques, and transverse abdominals, whereas dor-
sally the latissimus dorsi, thoracolumbar fascia, gluteus
maximus, and iliotibial tract contribute significantly.
Additionally, there appears to be an arthrokinetic reflex
mechanism by which the nervous system actively controls
this added support system. These supports are critical in
asymmetric loading, when the SI joint is most prone to
subluxation. The important concept to gain from this
understanding of integrated function with regard to treat-
ment and prevention of low back pain is that SIJD is a
"neuromyofascialmusculoligamentous" injury.
Coupled motion of contralateral latissimus dorsi and
gluteus maximus
Vleeming et al. [31] defined the posterior layer of the thora-
columbar fascia as a mechanism of load transfer from the
ipsilateral latissimus dorsi and the contralateral gluteus max-
imus (Fig. 3). This load transfer is critical during rotation of
the trunk, helping to stabilize the lower lumbar spine and
pelvis. This was demonstrated through cadaveric and electro-
myelographic (EMG) studies [32]. The stretched tissue of the
posterior thoracolumbar fascia assists the muscles by gener-
ating an extensor influence, and by storing elastic energy dur-
ing lifting to improve muscular efficiency.
Lumbopelvic rhythm and the hamstrings
Recent studies show there is both a functional and ana-
tomic connection between the biceps femoris muscle and
the sacrotuberous ligament [33–35]. This relationship
allows the hamstring to play an integral role in the intrinsic
stability of the SI joint. It appears that the biceps femoris,
often found to be short on the pathologic side in low back
pain, may actually be a compensatory mechanism via the
previously described arthrokinetic reflexes to help stabilize
the SI joint. In healthy individuals, a normal lumbopelvic
rhythm exists, during which the first 65° of forward bend-
ing is via the lumbar spine, followed by the next 30° via
the hip joints. Increased hamstring tension prevents the
pelvis from tilting forward, which diminishes the forward-
bent position of the spine, which results in reducing the
spinal load [36]. Normalization of the lumbopelvic
rhythm is an essential component to treatment of low back
pain and SIJD.
52 Spine Conditions
Gravitational strain
The model of suboptimal posture, though incomplete, has
shown to be effective when used as a model to guide treat-
ment [37–39]. Posture can be defined as the size, shape,
and attitude of the musculoskeletal system with respect to
gravitational force [40]. Subtle departure from ideal pos-
ture has been implicated as an important biomechanical
factor in athletes with regard to injury because it results in
increased mechanical stress throughout the body. Posture
must always be evaluated as part of the biomechanical
evaluation. The size, shape, and attitude of three cardinal
bases of support should always be included: standing sur-
face, the feet, and the base of the sacrum.
Tensegrity approach to the pelvis
Although still in development, a new biomechanical
model of body design is tensegrity [41], which refers to a
self-stabilizing system in which tension is continuously
transmitted across all elements. Therefore, the stability of a
tensegrity structure lies not in the strength of individual
members but in the ability of all the members to distribute
and balance mechanical forces. Current biomechanical
models of spinal mechanics view the spine as a column or
pillar. The sacrum as the base locks into the pelvis as a
wedge or other gravity-dependent closure. For human pos-
tures, this model may not explain the functionality
present. According to Levin [42•], “the hallmark of a pillar
is stability, but the hallmark of a spine is flexibility and
movement.” In the tensegrity model, triangulated struc-
tures (a truss) form the basis for inherently stable struc-
tures. When viewed three-dimensionally, they become the
tetrahedron, octahedron, and icosahedron. Further, the
sacrum, as opposed to being viewed as a wedge or base, is
suspended as a compression element within the ligamen-
tous tension system of muscles, ligaments, and fascia. To
date, cellular structure and mechanotransduction are
established by this system [43–45].
Diagnosis
History
An athlete who presents with pain in the area of the SI joints
requires a thorough history and physical examination. Ele-
ments of the history should include the following factors:
1. The age of the patient, because many conditions
occur within certain age ranges (ankylosing
spondylitis versus osteoarthritis).
2. The type of sport in which the patient is involved.
3. The acuteness or chronicity of the pain. Was there an
acute traumatic injury or a chronic repetitive injury?
4. The mechanism of injury.
5. For active pregnant women, remembering that
pregnancy causes laxity of the SI joint and predis-
poses women to pain or injury.
6. Identification of provocative and palliative measures.
7. The duration and frequency of the pain.
8. The quality and intensity of the pain as well as any
radiation or referred pain (usually unilateral, dull,
and deep, with radiation to buttock, posterior
thigh, or groin).
9. Notation of previous low back injuries, with the
treatments and outcomes.
10. The presence of red flags signaling more serious
pathology including , but not limited to, weight
loss, night pain and night sweats (cancer); fevers
and chills (infection); dysuria and hematuria
(nephrolithiasis); epigastric pain with nausea,
vomiting and/or heartburn (peptic ulcer disease or
pancreatitis); left-sided abdominal pain with mel-
ena, hematochezia, diarrhea and/or constipation
(diverticular disease); pulsating abdominal pain
with radiation to groin (abdominal aortic aneu-
rysm [AAA]); and numbness, tingling, weakness
and/or incontinence (radiculopathy or cauda
equine syndrome).
Physical examination
The physical examination begins with observation of the
athlete both statically and dynamically. One should evalu-
ate the patient in standing, supine, and prone positions,
and assess symmetry of the heights of the iliac crests, ante-
rior superior iliac spines, posterior superior iliac spines,
ischial tuberosities, gluteal folds, and greater trochanters,
as well as symmetry of the sacral sulci, inferior lateral
angles and pubic tubercles. Next, determine if there is any
leg length discrepancy. One should realize that true leg
length discrepancies will generally cause asymmetry and
pain, whereas a functional leg length discrepancy is usually
the result of SI joint and/or pelvic dysfunction. Assess pos-
ture for increased lumbar lordosis, which can result from
sacral torsions.
Dynamic observation assesses for any asymmetry dur-
ing both gait and specific motions characteristic of the
patient’s sport (eg, rowing). SI joint pain, pathology, and
restriction may cause a decrease in stride length, leading to
a limp or cause reflex inhibition of the gluteus medius,
leading to a Trendelenburg gait.
Next, the examiner should look for decreases in both
passive and active range of motion of the entire spine, hips,
and knees. If pain with motion testing occurs, the patient
should specifically identify the area of pain. One should
always perform a thorough examination of the lumbar
spine, hips, and knees because pathology in these areas can
refer pain to the SI joint. A neurologic examination for
radiculopathy should also be conducted, in addition to
evaluating abdominal strength and overall flexibility.
There have been numerous functional (motion) and
provocative (pain-producing) tests reported in the litera-
ture; however, none have consistently been shown to reli-
ably diagnose SI joint dysfunction [3,46–48]. We feel that
there are two major flaws in how these studies and others
 Sacroiliac Joint Dysfunction in Athletes • Brolinson et al.
like them have been carried out. Dreyfuss et al. [3] assumed
that pain production is an essential prerequisite to dys-
function. We feel that SIJD can be diagnosed based on
motion restriction and tissue texture changes, especially in
chronic pain syndromes when pain location can very
greatly due to muscle imbalance and other factors. They all
focus on assessing each test individually; however, SI
screening tests must always be followed up with segmental
motion testing and tissue palpation. When these tests are
used together with a thorough history to create a clinical
picture, they become significantly more reliable [49],
much like physical exam tests for meniscal tears. Research
is currently underway using SI joint injections under fluo-
roscopy to compare different provocative tests for reliabil-
ity and accuracy. A detailed discussion of the numerous
tests described for SIJD is beyond the scope of this review,
but the reader is referred to several excellent sources
[25•,27,50]. Common tests include standing forward flex-
ion, sitting forward flexion, stork (Gillet), Gaenslen,
supine-to-sit, Patrick (Faber), side-lying approximation,
and supine gapping. In osteopathic medicine, SI joint
somatic dysfunction is diagnosed primarily by the standing
and seated flexion tests, stork test, and asymmetry of pelvic
and sacral bony landmarks [27].
Differential diagnosis
The differential diagnosis of SIJD is broad, and includes
infection, inflammation (arthritic, metabolic and spondy-
loarthropothies), tumor (primary or metastatic), fractures
(stress or traumatic), pregnancy, osteitis condensans illi,
radiculopathies, spinal stenosis, facet syndrome, disco-
genic pain, hip disease, and vascular (AAA), gastrointesti-
nal, and genitourinary etiologies [1].
Diagnostic testing
There is no specific gold standard imaging test to diag-
nose SIJD, due largely to the location of the joint and
overlying structures that make visualization difficult.
However, standard radiographs taken at a 25° to 30°
from the AP axis, and lateral views may show degenera-
tive changes, ankylosis, demineralization or fracture [1].
Degenerative changes are usually first noted on the iliac
side of the joint. If sclerosis involves the lower two thirds
of the joint on both sides, sacroiliitis is common [51]. It
should be noted that in adolescents, the SI joints can
show widening and irregularity, and consequently can
make diagnosis difficult.
Bone scans identify osteoblastic activity, and may sig-
nal infection, tumor, fracture, or a metabolic process. Com-
puterized tomography will identify fractures, osteoid
osteomas, and degenerative changes. Ultrasound Doppler
imaging can capture SI motion in pregnant women with SI
pain [52]. Finally, magnetic resonance imaging (MRI)
helps to identify fractures, tumor, soft tissue pathology,
and lumbar disc disease. MRI is most sensitive for identify-
ing inflammatory sacroiliitis [1].
53
Treatment
Hypomobility
Traditional treatments of SIJD include analgesics, anti-
inflammatory agents, ice, heat, and physical rehabilitation.
We believe that a principle-centered, functional approach to
evaluation and rehabilitation must be undertaken [53••].
Physical therapy must focus rehabilitation on the entire
abdomino-lumbo-sacro-pelvic-hip complex addressing artic-
ular, muscular, neural, and fascial restrictions, inhibitions,
and deficiencies. The transverses abdominis has been shown
to be the key muscle to functional retraining the core, due to
its observed patterns of firing before and independent of the
other abdominal muscles [54]. Exercise techniques that pro-
mote independent contraction of the transverses abdominis
have been shown to lower recurrence rates after an acute low
back pain episode [55], and lower pain and disability in
chronic low back pain [56•]. Most recently, a study by Rich-
ardson et al. [57•] appears to show that these clinical benefits
focusing on the transverses abdominis occur due to signifi-
cantly reduced laxity in the SI joint. Correction of leg length
discrepancies, somatic dysfunction, inflexibility, and poor
posture is fundamental. SI belts may be helpful in pregnant
patients with hypermobile joints. Prolotherapy of the
lumbo-sacral-iliac region has been shown to be effective in
those athletes with chronic lumbar and SI joint pain due to
instability [58•,59–62].
Sacroiliac joint injection with or without fluoroscopy
has not been consistently shown to be effective [1,63–65],
although, theoretically it should help to diagnose the SI
joint as the source of pain. Similarly, periarticular injec-
tions also show inconsistent results [66,67].
In osteopathic medicine, manipulation is frequently
used to treat SIJD. These dysfunctions are termed restric-
tions, that is, pelvic and sacral hypomobility. Osteopathic
manipulation has been shown to be as efficacious as stan-
dard medical care in the treatment of patients with acute
and subacute low back pain [68•]. In addition, patients
treated with osteopathic manipulation typically required
less medication and physical therapy.
Several osteopathic techniques are utilized in the treat-
ment of SIJD, including soft tissue technique, muscle
energy, myofascial release, functional technique, strain-
counterstrain, cranial-sacral technique, and high velocity-
low amplitude. Explanations of these techniques and their
specific applications to the SI joint can be found in several
excellent sources [25•,27,29].
Sacroiliac joint instability
Chronic stress can cause connective tissue structures to
degenerate and lose their ability to compensate. Eventually
ligamentous laxity and hypermobility can occur. With a
joint already prone to subluxation based on its anatomy, to
which chronic additional stresses are applied, resultant SI
joint instability is not all that uncommon. Indirect insta-
bility can also occur through the additional forces applied
once levels above the SI joint become hypermobile. This is
54 Spine Conditions
commonly seen with spondylolisthesis and at times in
spondylolysis. Failure to identify the enthesopathy or ten-
donopathy that develops in the iliolumbar, SI, and sacrotu-
berous ligaments, and the attachments of the gluteals, and
erector spinae, can lead to incomplete resolution of symp-
toms or failure of treatment. These hypermobile areas with
chronic micromotion can be treated with prolotherapy
when gross instability and neurologic injury are absent.
When choosing hypermobile segments for prolother-
apy, one must try to differentiate between functional and
structural hypermobility, because treatment can be quite
different [69]. Structural hypermobility implies a fixed
defect, whereas functional hypermobility implies a com-
pensatory change that is able to be altered through manual
procedures and or exercise. Not all hypermobile regions
are structural.
Hypomobile somatic dysfunction can produce func-
tional or compensatory hypermobility in the early stages. If
the somatic dysfunction is left untreated, over time the dys-
functional segments will have structural hypermobility.
Clues to structural hypermobility are the bony exostoses at
attachments of postural muscles and ligaments on radiog-
raphy, which develop as a joint attempts to stabilize itself.
Comprehensive neuromuscular rehabilitation to supple-
ment the function of weakened ligaments should be
accomplished. Prolotherapy can then be used as an
adjunctive treatment to eliminate the remaining residual
structural hypermobility.
Gravitational strain
Recurrent somatic dysfunction and altered postural align-
ment should clue the physician in to the diagnosis of grav-
itational strain or postural imbalance. Gravitational strain
is a systemic neuromuscular response of postural align-
ment and muscle firing patterns to chronic gravitational
stress. Other findings may include chronic or recurrent
sprains/strains, pseudoparesis, recurrent articular dysfunc-
tion, recurrent myofascial trigger points, muscle imbal-
ance, and ligamentous laxity. Gravitational stress, an
obligatory consequence of bipedal posture, is a constant
and a greatly underestimated systemic stressor [70]. It is
most important that one understand that postural imbal-
ance is a systemic neuromuscular dysfunction. Initial treat-
ment in these chronic pain states must focus on the re-
education of the neuromuscular system. This is accom-
plished by seeking optimization of posture. This can be
achieved through the use of one or more of the following
modes of physical manipulation [40]: 1) contoured
orthotics worn in the shoes to optimize foot and lower
extremity biomechanics; 2) a flat orthotic of sufficient
thickness to level the sacral base; 3) manipulation and/or
mobilization directed to restore resilience to soft tissues
and motion of restricted joint segment; 4) daily practice of
a therapeutic posture for 20 minutes to counter the bias of
soft tissues reflective of the initial posture; and 5) use of
pelvic belts (sacral belts) or a levitor device for sacropelvic
support during the postural retraining process.
During the implementation of the above, a principle-cen-
tered, functional rehabilitation program [53••] that focuses
first on the stretching of tight, hypertonic postural muscles,
strengthening of weak phasic muscles, and proprioceptive
retraining must be carried out [71,72•,73,74]. It is critical to
remember that muscle imbalances must be eliminated, and
coordinated movement patterns returned to normal before
strengthening of the core can begin effectively.
Conclusions
Sacroiliac joint dysfunction is a well known clinical entity
in the athletic population. Despite this, its diagnosis, eval-
uation, and treatment remains problematic. Given the
number of sports that can potentially stress and injure this
region, we must continue to refine our biomechanical
models and treatment paradigms to better serve athletes
with SIJD and pain. We believe that a comprehensive func-
tional approach based on historic clues and appropriate
diagnostic testing will lead to an accurate diagnosis. The
appropriate therapeutic approach can then be selected.
Our experience is that a multimodal approach works best,
and often includes SI joint mobilization or manipulation.
Identification and correction of functional or anatomic
leg-length discrepancy is an important but often over-
looked clinical entity. The influence of proximal or distal
structures is poorly appreciated, but must be considered,
especially with regard to postural retraining. Finally, the
biomechanical demands of the athlete’s sport must be
carefully evaluated in the design of the rehabilitative envi-
ronment, ultimately resulting in the successful return of
the athlete to his or her sport.
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Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
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