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MSPT II > SI Joint Eval & Tx > Flashcards

SI Joint Eval & Tx Flashcards

1
Q

SI Joint

2 Components

A
  1. Ilium
  2. Sacrum
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2
Q

Long standing controversy regarding Role of SIJ in LBP:

2 Extreme Views

A
  1. Largely dismissed functionally 2* to little or no mvmt
  2. Has important primary mvmts that can be assesed as other jts
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3
Q

SIJ

FACTS:

A
  • Cannot be considered as any other jt in body
    • ​mvmts= small
    • not endowed w/ muscles that execute active mvmts
  • Structurally and functionally more comparable to intertarsal jts of foot
  • Needs to be both stable and mobile
  • Motion occurs via action of mm’s moving adjacent bony structures AND GRF’s
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4
Q

2 Unique Roles of the Sacrum

Directions?

2:

A
  1. Longitudinally
  2. Transversely
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5
Q

2 Unique Roles of the Sacrum

1. Longitudinally

A
  • Supports L/S, all long. forces delivered to L/S transmitted to sacrum
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6
Q

2 Unique Roles of the Sacrum

2. Transversely

A
  • Consitutes post. wall of the pelvis, transmits forces sideways from the VC into the pelvis and vice versa
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7
Q

SIJ as a Functional Unit

A
  • L5-S1
  • SI jts (L and R)
  • Symphysis Pubis
  • Bones: 2 Innominates; Sacrum
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8
Q

Architecture/Morphology of SIJ

A
  • Part synovial, part syndesmosis
  • Sacral surface cartilage→ largely hyaline, 2-3x thicker than iliac
  • Iliac surface cartilage→ mix of mostly hyaline w/ fibrocart.
  • Surfs irregular→ vary in lvl congruency
  • Bonnaire’s Tubercle→ on iliac surf of SIJ b/w upper and lower aspects
    • pivot point for Nutation/Counternutation
  • Sacrum wider dorsally at S1 and wider ventrally @ S3
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9
Q

Nutation

A

Occurs as sacrum moves anteriorly and inferiorly while the coccyx moves POST relative to ilium

*coccyx pulled UP

Think “cocking it into place pulling coccyx up”

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10
Q

Counternutation

A

Occurs as sacrum moves POST and SUP while the coccyx moves ANT relative to ilium

“pushing Coccxy IN”

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11
Q

Nutation/Counternutation Ex.

A

WALKING!

*may be some degree of nutation on one side and counternutation on the other side

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12
Q

SIJ

Ligs/Joint Cap

Interosseus Ligament

A
  • MOST IMPORTANT ligament of the SIJ
  • Lies deep in the narrow recess b/w sacrum and ilium, dorsal to joint cavity
  • Functions to strongly bind sacrum TO ilium
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13
Q

SIJ Ligs

Post. SI Ligament

A
  • Connects intermed and lateral crests of sacrum TO PSIS and post end of inner lip of iliac crest
  • Acts in concert w/ interosseus lig to bind sacrum to ilium
  • Mostly prevents post flaring or diastasis of the joint
  • Longer fibers of lig prevent backward rocking (counternutation) of sacrum
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14
Q

SIJ Ligs

Anterior Sacroiliac Lig

A
  • Covers ventral (FRONT) aspect of joint
  • Transverse fibers running from ala (wings) and ant surf of sacrum to the ant surf of ilium
  • Attach’s are of considerable dist beyond the margins of the joint
  • encompasses the ant. cap of SIJ
  • Binds ilium to sacrum
  • Prevents ANT diastasis (flairing) of joint (nutation)
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15
Q

Sacrospinous Ligament

A
  • “sacro”-sacrum TO “spinous”- ischial spine
  • broad orig. from the lat edge BELOW SIJ converging on the ischial spine
  • Prevents nutation (forward rocking of sacrum) → remember think cocking coccyx BACK
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16
Q

Sacrotuberous ligament

A
  • Orig’s from multiple points on sacrum:
    • PSIS
    • Transv tubercles of lower sacral segs
    • Inf Lat. margin on sacrum
    • Broad attach to medial margin of isch tuberosity
  • Superf fibers of lig are cont w/ long head of biceps fem tendon
  • Prevents nutation of sacrum
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17
Q

MM’s affecting SIJ

A

QL

Multifidi and Erectors→ contraction produces nutation of sacrum

Psoas

Iliacus

Glute max

Biceps fem

Rec fem

Adductors

Hip rotators

TA

coccygeus (pelvic floor mm’s)

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18
Q

Jt mechs of SIJ

A
  • Bony locking mech prevents downward motion of sacrum under BW
  • Sacrum set obliquely b/w ilia→ SUP end leans ventrally
  • Under vertical loads it tilts forward and downward→ nutates (forward rock) around Bonnaire’s Tub
  • Shape of sacrum gives bony opposition to nutation
  • Ligs keep mvmts minimal****
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19
Q

SIJ Changes across lifespan

A
  • 0-10→ highly mobile, jt plane close to vertical
  • 10-30→ jt plane becomes oblique
  • 40→ osteophytes form, capsule thickens, DJD
  • 50-60→ motion DECs
  • 60-80→ ankylosis (fusing)
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20
Q

Prevalence SIJ Disorders

A

~15% of pts w/ chronic LBP

21
Q

SIJ Disorders

Gender Diffs

A
  • Pregnancy→ hypERmobile (Relaxin hormone)
  • More accel’d ankylosis in males
  • Female SIJ smaller, flatter=> more mobile
  • COG and SIJ: Females
    • SAME frontal plane
  • COG and SIJ: Males
    • COG more ventral
22
Q

Diff Dx SIJ

A

Validity of many mech tests questionable

Sx distribution is poor indicator BUT pts w/ SIJ probs typ have no pain above waist

23
Q

Possible historical and Dx Clues for SIJ patho

A
  • Trauma→ long axis force thru femur OR direct fall on one isch tub (miss chair)
  • Inj inolving twist or asymm motions
  • pain rolling side to side
  • pain ascend/descend stairs
  • WB acts may be provocative
  • pregnancy/post-partum
  • pain w/ arising from seated pos
  • absence of midline lumbar pain w/ buttock pain
24
Q

EXAM for SIJ

clear lumbar spine and hip first

HOW?

A

LOOK @ ALL OTHER SUBGROUPS FIRST:

  • Manip?
  • Directional pref?
  • Instability?
  • THEN SI
25
Q

3 tests you should do for SI FIRST!!!

A
  1. SI Compress/Distract
  2. Sacral Thrust
  3. Thigh Thrust
26
Q

International Ass. for the Study of Pain Dx criteria for Symptomatic SIJ

A
  • Pain present in area of SIJ
  • Selective stressing of SIJ by clin provocation that repros pain
  • selective infiltration of the symptomatic SIJ w/ anesthetic completely relieves pain
27
Q

Special Tests for SIJ:

PROVOCATION TESTS

*Highest reliability and validity

A
  • Laslett found these 4 contributed to making dx of SIJ pain and dysf
  • Robinson found reliability of pain prov tests was mod to good while reliability of palp was poor
28
Q

Special Tests for SIJ:

PROVOCATION TESTS

4:

A
  1. SI Distraction
  2. Thigh Thrust
  3. SI Compression
  4. Sacral Thrust
29
Q

Special Tests for SIJ:

PROVOCATION TESTS

SI Distraction Test

30
Q

Special Tests for SIJ:

PROVOCATION TESTS

Thigh Thrust

31
Q

Special Tests for SIJ:

PROVOCATION TESTS

SI Compression Test

32
Q

Special Tests for SIJ:

PROVOCATION TESTS

Sacral Thrust

33
Q

Laslett’s Clinical Dx Rule for SIJ

*Perform SI Distraction and Thigh Thrust tests FIRST!!! ****

A
  • Inclusion vs. exclusion Gaenslen’s test did not sig. alter results
  • *When all provocation SIJ tests are NEGATIVE→ SIJ Patho can be R/O
  • Thigh Thrust→ greatest Sn→ .88 (SnNOUT)
  • Distraction→ greatest Sp→ .81 (SpPIN)
  • OPTIMUM RULE:
    • perform distraction and thigh thrust FIRST

*NOTE: if familiar sx’s not provoked→ cont. w/ remaining tests until a total of 2 positives found

34
Q

Special Tests of SIJ: Mobility/Palpation/Pos Tests

What should you know about these?

A

In general, poor reliability and validity***

35
Q

Special Tests of SIJ: Mobility/Palpation/Pos Tests

Support Side Stork Test

(*Stork think standing on one leg like a stork****)

A

see pics

*NOTE: relative to other mobility/palpation/pos tests→ this one had GOOD reliability found w/ stork test on the support side

36
Q

Special Tests of SIJ: Mobility/Palpation/Pos Tests

Support Side Stork Test

A
  • Negative Test: innominate rotation POSTERIORLY (moves caudal) on the support side relative to the sacrum OR stayed relatively neutral
    • *this test assesses the joint in a loaded pos. to det normal stability
  • POSITIVE Test: innominate rotation SUPERIORLY (moves cephalad) on support side relative to sacrum
    • Interpretation: indicates failure of self-bracing mech. to maint. SIJ in ints closed pack pos.
      • i.e.→ POSITIVE test is suggestive of SIJ instability or hypermobility on the stance leg
37
Q

Special Tests of SIJ: Mobility/Palpation/Pos Tests

Gilet’s (Sacral Fixation) Test

*almost same as stork test but now you palpate PSIS on hip that is flexing up (non-supported side)

A

Almost same as Stork Test, but palpate PSIS on same side as the hip that pt is flexing

Thus, in this case you are assessing unloaded (NWB) side

38
Q

Special Tests of SIJ: Mobility/Palpation/Pos Tests

Seated Flexion Test (Piedallu’s Sign)

A
  • Are PSIS lvl @ start w/ pt seated?
  • Do they remain lvl as pt flexes forward?
  • IF NOT→ indicative of SI jt imbalanace OR perhaps hypOmobility on 1 side
    • *Magee’s Interpretation: if one PSIS is LOWER in upright sitting then appears HIGHER after forward bend→ that side is hypOmobile
39
Q

Gaenslen’s Test

SEE LAB NOTES!!!!!

40
Q

Special Tests of SIJ: Mobility/Palpation/Pos Tests

Supine-to-Sit Test

*MAKE SURE YOU HAVE THEM DO A BRIDGE FIRST TO SET THE PELVIS

A
  • Interpretation:
    • If leg on PFL side appears LONGER in supine and then SHORTER in long-sitting→ Innominate on that side= Anteriorly rotated***
    • If leg on PFL side appears SHORTER in supine and then LONGER in long-sitting→ Innominate on that side=Posteriorly rotated***
41
Q

Special Tests of SIJ: Mobility/Palpation/Pos Tests

Palpation of PSIS, ASIS, Iliac Crest Hts

A
  • Interpretation of findings on PFL Side:
    • PSIS HIGHER, Iliac crest HIGHER, ASIS LOWER=> ANT rotated innominate on PFL side
    • PSIS LOWER, ASIS HIGHER=> POST rotated innominate on PFL side

NOTE: Pelvic Asymmetry: No meaningful assoc. w/ back pain***

42
Q

Interventions for SIJ Dysf.

Directional Preference Ex.

*if they have one…

A
  • Force transmitted to the SIJ via trunk or LE motions
  • Hip flex vs. hip ext.
  • Lunges w/ R vs. L LE ant (in front, like a split lunge)
  • May have to alter hip IR or ER
43
Q

Interventions for SIJ Dysf.

Muscle Energy Techniques****

First determine direction of innominate rotation

Anteriorly Rotated Innom.

A
  • IF proble is ANTERIORLY rotated innominate:
    • GOAL= correct it by POSTERIORLY rotating it
      • SKTC on affected side
      • foot UP on table/chair (affected side foot UP)
      • lunging w/ involved side forward
      • MM Energy Techs using the hip ext’s→ ISO. contraction of hip ext’s generates POST ROT. moment on innominate
        • bc EXT’s pull pelvis POST
      • *majority of pts w/ SIJ probs respond to tx involving post rotation forces on innominate
44
Q

Interventions for SIJ Dysf.

Muscle Energy Techniques****

First determine direction of innominate rotation

Posteriorly Rotated Innominate

A
  • IF problem is a POSTERIORLY Rotated Innominate:
    • GOAL= correct it by ANTERIORLY rotating innominate
      • Stretching into HIP EXT (on affected side)
      • Lunging w/ involved side BACK
      • MM Energy Techs→ ISO. contraction of HIP FLEXORS
        • ISO contract of hip flexors generates ANT. ROT. moment on innominate
        • bc these mm’s pull pelvis ANTERIORLY
45
Q

Interventions for SIJ Dysf.

Muscle Energy Techniques****

First determine direction of innominate rotation

3 other ways if its both sides rotated diff directions

A
  1. Ant/Post rotation via resisted hip flex/ext in hooklying
  2. End range Ant/Post rotation via resisted hip flex/ext
  3. Pubic Shotgun
    1. pt in hooklying
    2. PT briefly and firmly resists hip ABD (B/L) 3x
      1. 1st w/ knees close together
      2. 2nd w/ knees slight apart
      3. 3rd knees more wide apart
    3. NEXT.. PT repos’s hands to resist ADD (B/L) of hips
      1. as pt ADD’s, PT pushes OUTWARDLY into ABD w/ a quick thrust
      2. *** SEE LAB NOTES!!!
46
Q

Special Tests of SIJ: Mobility/Palpation/Pos Tests

Gentle Mob. Tech’s aka Iliac Rocking

A
  1. STM→ Sacrotuberous lig
    1. palp inf lat angle of sacrum off the coccyx and the isch tub- lig is ½ way b/w these two
    2. mobilize into rolling motion about 1min
  2. Stab. Belts
  3. Lumbopelvic Stab. Ex Program
    1. TA, Pelvic Floor
    2. *we want them to work in the “new corrected” pos.
  4. Bridging w/ alternating hip ADD or ABD stab. ex.
47
Q

In general

If innominate is ANT ROTATED…

A

You want to STRETCH the Hip EXT’s OR ISO contraction of HIP EXTs

48
Q

In General,

If Innominate is POSTERIORLY ROTATED

A

You want to STRETCH hip flexors OR ISO contraction of Hip flexors

MSPT II (20 decks)

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