SIJ Flashcards
1
Q
SIJ - ROM
A
- Flexion/extension - 0-10
- Internal/external rotation - 0-10
2
Q
SIJ - MYOTOMES
A
- Trunk rotation - T6, T7, T8, T9, T10, T11, T12, L1, L2 - segmental nn
- Trunk lateral flexion - T6, T7, T8, T9, T10, T11, T12, L1, L2 - segmental nn
- Trunk flexion/extension - T6, T7, T8, T9, T10, T11, T12, L1, L2 - segmental nn
- Hip flexion - L1, L2, L3 - femoral nerve
- Knee extension - L3, L4 - femoral nerve
- Knee flexion - L4, L5, S1, S2 - sciatic nerve
- Ankle dorsiflexion - L4, L5 - deep peroneal nerve
- Ankle inversion - L4, L5 - tibial nerve, deep peroneal nerve
- Ankle eversion - L5, S1 - superior peroneal nerve
- Big toe extension - L5, S1 - deep peroneal nerve
- Big toe flexion - L5, S1 - tibial nerve
3
Q
SIJ - ORTHO TESTS - SCREENING
A
- SCREENING - Flamingo test
4
Q
SIJ - ORTHO TESTS - SIJ DYSFUNCTION
A
- SI JOINT DYSFUNCTION - Step test
5
Q
SIJ - ORTHO TESTS - SI SPRAIN/STRAIN
A
- SI SPRAIN/STRAIN - Sacral shear
6
Q
SI - ORTHO TESTS - ILIOPSOAS CONTRACTURE
A
- ILIOPSOAS CONTRACTURE - Gaenslen’s test
7
Q
SIJ - JOINT TYPE
A
- Cartilagenous (syndesmosis) - pubic symphysis
- Gliding (cartilagenous and syndesmosis regions)- SI
8
Q
SIJ - ARTICULAR SURFACES
A
- Sacrum - concave
- Ilium - convex
- Sacroiliac - facets orientated 45 from sagittal
- Fibrocartilage on ilium & hyaline cartilage on sacrum (FISH - fibro ilium, sacrum hyaline)
- Cartilage is 2-3x thicker on the sacrum
- After 60 most males have a fused SI joint
9
Q
SIJ - RESTING POSITION
A
Neutral
10
Q
SIJ - CLOSED PACKED POSITION
A
Full nutation (SI flexion)
11
Q
SIJ - NORMAL END FEEL
A
Firm ligamentous tissue stretch
12
Q
SIJ - COUPLED MOTIONS
A
- Sacral motion is also coupled with lumbar motion
- Lumbar extension (or hyperlordosis) is coupled with sacral nutation (anterior sacral tilting or “nod”)
- Lumbar flexion (or hypolordosis) is coupled with sacral counter-nutation (posterior sacral tilting)
- Rotation of the SI joint follows the lumbar pattern
13
Q
SIJ - CONDITIONS - ANKYLOSING SPONDYLITIS
A
Hx - prior trauma - fall onto shoulder or impact over shoulder
S&S - possible step defect; tenderness to palpation over AC joint; +ve Obrien’s
DDx - supraspinatus rupture, impingement syndrome, rotator cuff tear
14
Q
SIJ - CONDITIONS - CAUDA EQUINA SYNDROME
A
Hx - Pt age 40-60, usually female, weeks of shoulder pain and restriction
S&S - restricted AROM in clear capsular pattern (external rotation > abduction > internal rotation); extermally painful & limited PROM
DDx - cervical pathology, impingement syndrome, rotator cuff tear
15
Q
SIJ - CONDITIONS - DISC HERNIATION
A
Hx - pain over anterior shoulder, history of repetitive elbow flexion (weight lifter)
S&S - pain with direct palpation of biceps long head tendon; pain with resisted horizontal adduction
DDx - cervical pathology, rotator cuff strain
16
Q
SIJ - CONDITIONS - LUMBAR (DJD) OSTEOARTHROSIS
A
Hx - pain over superior or lateral GH joint, pain at night, difficulty sleeping
S&S - tender palpation over acromion/deltoid; decreased shoulder ROM in abduction & flexion; pain may be relieved by GH inferior distraction
DDx - cervical pathology, ortator cuff strain, impingement syndrome
17
Q
SIJ - CONDITION - LUMBAR JOINT DYSFUNCTION
A
Hx - insidious onset of pain, morning stiffness, worse with excessive activity
S&S - crepitus and pain with ROM; +ve Ellman compression test
DDx - AC OA, GH instability, impingement syndrome
18
Q
SIJ - CONDITION - SIJ STRAIN/SPRAIN
A
Hx - history of trauma, local pain with motion
S&S - no neurologic signs; decreased AROM and PROM, PROM due to pain
DDx - lumbar joint dysfunction often coexist
19
Q
SIJ - CONDITION - PELVIS FRACTURE
A
Hx - significant trauma, severe pain
S&S - gait abnormalities; +ve SI compression, distraction stress test
DDx - visible on x-ray or CT scan, severe SI sprain
20
Q
SIJ - CONDITION - SI INSTABILITY
A
Hx - chrinic SI pain, possible repeatable “clunk” of SI joint; may occur during or shortly after pregnancy
S&S - +ve sacral glide test for increased motion
DDx - SIJ dysfunction, lumbar instability
21
Q
SIJ - CONDITION - SPINAL STENOSIS
A
Hx - M>F (2:1), chronic low back pain, worse with prolonged standing
S&S - decreased AROM & PROM; confirm with x-ray, decreased spinal canal diameter
DDx - vascular claudication
22
Q
SIJ - CONDITION - SIJ DYSFUNCTION
A
Hx - insidious onset of local pain or discomfort (may be due to fall on sacrum)
S&S - tender to palpation; limited joint play; local myospasm; bone out of place
DDx - lumbar sprain/strain, PI ilium or AI (neutered) sacrum are most common
23
Q
SIJ - CONDITION - PIRIFORMIS SYNDROME
A
Hx - possible pain down back of leg, worse when sitting on a hard surface
S&S - tender to palpation, +ve SLR, sign of the buttock, +ve piriformis test
DDx - lumbar radiculopathy, disc herniation, lumbar sprain/strain, stenosis
24
Q
SIJ - ORTHO TESTS - SI MARCHING TEST
A
- Pt standing with arm against wall, examiner palpates the PSIS and S2 tubercle (SP)
- Pt is instructed to flex ipsilateral hip to 90, examiner palpates motion of PSIS relative to S2 (normally the PSIS moves closer to S2 tubercle)
- Examiner then instructs the patient to flex contralateral hip to 90, examiner observes/palpates motion of S2 relative to PSIS (normal motion should move S2 away from PSIS)
- Repeat test on contralateral SI joint
25
SIJ - ORTHO TESTS - SI MARCHING TEST - POSITIVE TEST
**SI or pubic joint sprain, pelvic fracture**
- Pain
**Hyper mobility, joint dysfunction**
- Excess motion
**Ipsilateral SIJ dysfunction**
- Decreased ROM
26
SIJ - ORTHO TESTS - BELT TESTS
- Pt standing
- Instruct pt to band forward and touch toes with knees straight and return to standing
- Examiner then stabilises the pt pelvis bilaterally over the ASISs with hands and pt sacrum with examiners lateral thigh
- Pt is then instructed to repeat motion of touching toes
27
SIJ - ORTHO TESTS - BELT TESTS - POSITIVE TEST
**Lumbar spine pathology**
- Pain with supported and unsupported flexion
**SIJ pathology**
- No pain with support
- Pain with support
28
SIJ - ORTHO TESTS - ACTIVE SLR
- Pt supine
- Examiner instructs pt to lift affected leg 15cm off the table
- If movement in painful examiner stabilises pelvis by compressing ober ASISs and asks pt to repeat movement
29
SIJ - ORTHO TESTS - ACTIVE SLR - POSITIVE TEST
**Pelvic fracture**
- Inability to raise leg
- Pain with pelvic stabilisation
**SI lesion**
- No pain with SI stabilisation
30
SIJ - ORTHO TESTS - ACTIVE SLR - SN & SP
**Pelvic fracture**
**SN**: 90
**SP**: 95
**SI lesion**
**SN**: 77-87
**SP**: 55-94
31
SIJ - ORTHO TESTS - FLAMINGO TEST
- Pt standing
- Pt stands on one leg and hop in place
- Examiner observes for signs of discomfort or pain
- By standing on one leg pressure is increased on the ipsilateral hip, SIJ & pubic symphysis
32
SIJ - ORTHO TESTS - FLAMINGO TEST - POSITIVE TEST
**SIJ dysfunction, hip joint lesion (pain secondary to trauma may indicate fracture)**
- Local SI pain
33
SIJ - ORTHO TESTS - GAENSLEN'S TEST
- Pt supine
- Examiner flexes knees and though of affected leg to pt abdomen
- Examiner then slowly hyperextends the opposite leg
- Observe pt for signs of pain
- Repeat the test on the opposite leg
34
SIJ - ORTHO TESTS - GAENSLEN'S TEST - POSITIVE TEST
**SIJ pathology (ligamentous sprain, instability)**
- SI pain
- Anterior thigh pain
**Iliopsoas contracture**
- Elevation of extended hip
**Possible lumbar or hip pain origin (if the leg hanging off the table starts to straighten look for iliopsoas contracture)**
- No SI pain
35
SIJ - ORTHO TESTS - GAENSLEN'S TEST - SN & SP
**SN**: 50-71
**SP**: 26-77
36
SIJ - ORTHO TESTS - THIGH THRUST
- Pt supine
- Painful side hip flexed 90 and knee flexed
- Examiner stands on opposite side of pain and places hand under sacrum to create a bridge
- Examiner then applies downward pressure on femur and attempts to stress SIJ
37
SIJ - ORTHO TESTS - THIGH THRUST - POSITIVE TEST
**SI pathology**
- SIJ pain
**Hip joint pathology**
- Hip pain
38
SIJ - ORTHO TESTS - THIGH THRUST - SN & SP
**SN**: 80-93
**SP**: 69-100
39
SIJ - ORTHO TESTS - SI COMPRESSION
- Pt supine
- Examiner places hands bilaterally on lateral pelvis
- Applies pressure from lateral to medial (compressing pelvis)
40
SIJ - ORTHO TESTS - SI COMPRESSION - POSITIVE TESTS
**SI sprain/strain, fracture, SIJ dysfunction**
- Pain
**SI instability (instability is also indicated if pt stands with feet wide apart and pain is reduced - abducted hips increase SIJ compression and pelvic stability)**
- Decreased pain
41
SIJ - ORTHO TESTS - SI COMPRESSION - SN & SP
**SN**: 25-69
**SP**: 63-100
42
SIJ - ORTHO TESTS - SI DISTRACTION
- Pt supine
- Examiner places hands bilaterally over the pt ASIS
- Examiner applied force downwardly and laterally in an attempt to distract the pelvis
43
SIJ - ORTHO TESTS - SI DISTRACTION - POSITIVE TEST
**Anterior SI or pubic joint strain, pelvic fracture**
- Pain
44
SIJ - ORTHO TESTS - SI DISTRACTION - SN & SP
**SN**: 11-60
**SP**: 74-100
45
SIJ - ORTHO TESTS - SEATED FLEXION TEST
- Pt seated
- Examiner locates the PSIS bilaterally
- If one PSIS is higher than the other, get the pt to flex forward
- Examiner observes pt for pain or apprehension
46
SIJ - ORTHO TESTS - SEATED FLEXION TEST - POSITIVE TEST
**SIJ dysfunction, abnormality in torsion movement**
- Lower PSIS becomes higher with forward flexion
**SIJ dysfunction**
- Pain with forward flexion
47
SIJ - ORTHO TESTS - SEATED FLEXION TEST - SN & SP
**SN**: 69
**SP**: 98
48
SIJ - ORTHO TESTS - SACRAL THRUST
- Pt prone
- Examiner places palm over spinal level S2
- Examiner applies pressure directly downwards
49
SIJ - ORTHO TESTS - SACRAL THRUST - POSITIVE TEST
**SIJ dysfunction**
- Pain
50
SIJ - ORTHO TESTS - SACRAL THRUST - SN & SP
**SN**: 63
**SP**: 75
51
SIJ - ORTHO TESTS - LASLET'S CLUSTER
- Thigh thrust
- Sacral thrust
- SI compression
- SI distraction
- Gaenslen’s
- Sometimes gaenslen’s is not part of the test
52
SIJ - ORTHO TESTS - LASLET'S CLUSTER - POSITIVE TEST
**SIJ dusfunction**
- 2/4 positive tests
- 3/5 positive tests (when gaenslen’s is included)
53
SIJ - SIJ PAIN
- Felt in the low back and buttocks. The pain is caused by damage or injury to the joint between the spine and hip
54
SIJ - SIJ PAIN - CAUSES
- Tight ligaments
- Uneven pelvic movement
- Arthritis
- Scoliosis
- Traumatic injury
- Pregnancy
55
SIJ - SIJ PAIN - POPULATION AFFECTED
- Young/middle aged women who are or have recently been pregnant
56
SIJ - SIJ PAIN - CLINICAL PRESENTATION
- Pain is most commonly felt in the low back and one side of the buttocks but can also be referred into the thigh and leg.
- Stiffness and limited ROM in lower back and hips/pelvis region
- Instability, may cause pelvis to feel like it will give way
- Pain can be aggravated with prolonged sitting or standing, standing on one leg, stair climbing, going from sit to stand, and with running.
57
SIJ - ILIOPSOAS BURSITIS
- Inflammation of the bursa located beneath the iliopsoas muscle
58
SIJ - ILIOPSOAS BURSITIS - CAUSES
- Result of multiple mini traumas caused by vigorous hip flexion and extension - friction from the overlying tendons.
59
SIJ - ILIOPSOAS BURSITIS - POPULATION AFFECTED
- Most common in women 40-60
- Commonly seen in individuals participating in strength training, rowing, uphill running and competitive track and field.
60
SIJ - ILIOPSOAS BURSITIS - CLINICAL PRESENTATION
- Pain located in the anteromedial aspect of the thigh, radiating into the knee, leg and lower back
- Develops during walking or specific movements like crossing the legs
- Worse while performing activities
- Relieved by rest
- Tenderness in superior proximal aspect of the quadriceps muscles
- Stiffness or pain after a rest or in the mornings.
61
SIJ - PIRIFORMIS SYNDROME
- Piriformis muscle, spasms and causes buttock pain. Can also irritate the nearby sciatic nerve and cause pain, numbness and tingling along the back of the leg and into the foot (similar to sciatic pain).
62
SIJ - PIRIFORMIS SYNDROME - POPULATION AFFECTED
- Most common <45
63
SIJ - PIRIFORMIS SYNDROME - CAUSES
- Sitting for prolonged periods (taxi drivers, office workers, bicycle riders)
- Trauma to the hip or buttock area
64
SIJ - PIRIFORMIS SYNDROME - CLINICAL PRESENTATION
- Chronic pain in the buttock and hip area
- Pain when getting out of bed
- Inability to sit for a prolonged time
- Pain in the buttocks that is worsened by hip movements
- Pts will often present with symptoms of sciatica
65
SIJ - OSTEITIS PUBIS
- Painful and chronic condition affecting the pubic symphysis and/or parasymphyseal bone that develops after athletic activity.
66
SIJ - OSTEITIS PUBIS - POPULATION AFFECTED
- Most common men 30-50
- Pregnant women
- Children due to the shearing motion
67
SIJ - OSTEITIS PUBIS - CLINICAL PRESENTATION
- Lower abdominal pain
- Groin pain, with radiation to inner thigh/adductor muscles
- Often associated with gait disturbances
- Discomfort exaggerated by any activity that puts pressure on the pelvic griddle, e.g. walking, especially up and down the stairs, couching/sneezing
- Pain described as dull ache
68
SIJ - ISCHIOGLUTEAL BURSITIS
- Inflammation of the bursa, which lies between the ischial tuberosity and the gluteus maximus muscle
69
SIJ - LEVATOR ANI SYNDROME
- Rare but exquisitely painful condition characterised by intermittent burning pain and the feeling of an incomplete bowel movement in the rectum and perineal region.
70
SIJ - LEVATOR ANI SYNDROME - CLINICAL PRESENTATION
- pain high in the rectum that may be:
- irregular and spontaneous, a dull ache
- relieved when standing or lying down but felt when sitting
- unrelated to bowel movements
- severe enough to interrupt sleep
- Episodes of chronic or recurrent rectal pain or aching that last for at least 30 minutes
- Tenderness of the puborectalis muscle (which wraps around the rectum and the pubic bone) when it is touched
71
SIJ - COCCYDYNIA
- Pain in the bone at the base of the coccyx.
72
SIJ - COCCYDYNIA - CAUSES
- injury or accident, such as a fall onto your coccyx
- Repeated or prolonged strain on the coccyx – for example, after sitting for a long time while driving or cycling
73
SIJ - COCCYDYNIA - POPULATION AFFECTED
- Pregnancy and childbirth
74
SIJ - COCCYDYNIA - CLINICAL PRESENTATION
- dull and achy pain at the base of spine most of the time, with occasional sharp pains:
- The pain may be worse:
- when you sit down or stand up
- when you bend forward
- when using the toilet
75
SIJ - MOVEMENTS AVAILABLE
Very limited amount of movement at this joint
- Nutation (frontal plane)
- Counternutation (frontal plane)
- Torsion (transverse plane)
76
SIJ - NUTATION
Movement that occurs when force (weight) is absorbed at the SIJ and occurs in the direction of gravitational forces
- Occurs when the sacrum moves anteriorly and inferiorly, the coccyx moves posteriorly relative to the ilium
77
SIJ - COUNTERNUTATION
The bodys response to lifting the joint up against gravity
Limited to 2 to 4mm of movement in most people
- Occurs when the sacrum moves up, backward and rotates to the same side that absorbs the force
78
SIJ - TORSION
Torsion occurs when the right or left base of the sacrum moves anterior or posterior although only 1.5 degrees of torsion occur at the SIJ
79
SIJ - JOINT
- SIJ is a diarthrodial synovial joint
- Surrounded by a fibrous capsule containing a joint space filled with synovial fluid between the articular surfaces
- Iliac capsular surface is composed of fibrocartilage
80
SIJ - ANTEIROR SI LIGAMENT
- An anteroinferior thickening of the fibrous capsule that is weak and thin when compared to the other ligaments of the joint
- It connects the third sacral ligament to the lateral side of the preauricular sulcus and is better developed closer to the arcuate line and the PSIS
- This ligament is injured most often and is a common source of pain because of its thinness
81
SIJ - INTEROSSEOUS SI LIGAMENT
- Forms the major connection between the sacrum and the innominate and is a strong, short ligament deep to the posterior sacroiliac ligament
- It resists anterior and inferior movement of the sacrum
82
SIJ - POSTERIOR SI LIGAMENT
- Connects the PSIS with the lateral crest of the third and fourth segments of the sacrum and is very stong and tough
- Nutation, which is anterior motion of the sacrum, slackens the ligament, and counternutation, which is posterior motion will make the ligament taut
- It can be palpated directly below the PSIS and can often be a source of pain
83
SIJ - SACROTUBEROUS LIGAMENT
- Consists of three large fibrous bands and is blended with the posterior (dorsal) sacroiliac ligament
- It stabilizes against nutation of the sacrum and counteracts against posterior and superior migration of the sacrum during weight bearing
84
SIJ - SACROSPINOUS LIGAMENT
- Triangular shaped and thinner than the sacrotuberous ligament and goes from the ischial spine to the lateral parts of the sacrum and coccyx and then to the ischial spine laterally
- Along with the sacrotuberous ligament, it opposes forward tilting of the sacrum on the innominates during weight bearing
85
SIJ - NERVES
- Ventral rami of L4-L5
- Superior gluteal nerve
- Dorsal rami of L5-S2
86
SIJ - HOW MANY MUSCLES ATTATCH TO THE SACRUM OR INNOMINATES?
35
87
SIJ - EPIDEMIOLOGY
- 10-27% of people suffer with SIJ pain
88
SIJ - PREDISPOSING FACTORS
- Leg length discrepancy
- Age
- Arthritis
- Previous spinal surgery
- Pregnancy
- Trauma
89
