Have you ever experienced a nagging pain in your low back, above the back of your hip? This area below your lower back is known as your sacroiliac joint or “SIJ” as we call it- the region where the top of your tailbone, also called your sacrum, attaches with your pelvis. Pain at this region can be a little more difficult to treat, as there are a variety of reasons that may be contributing to this problem! People often have a hard time explaining this pain and where it is located. In this blog we will be discussing the structures of the SIJ, common risk factors/ mechanisms of injury, and how we go about treating this condition.
Anatomy of the SIJ
The sacroiliac (SI) joint is a complex joint formed by the connection between the sacrum and the ilium. Several anatomical structures contribute to the stability and function of the SI joint:
Sacrum: The sacrum is a triangular bone located at the base of the spine, formed by the fusion of five sacral vertebrae. It serves as the foundation of the spine and provides support for the pelvis.
Ilium: The ilium is one of the three bones that make up the hip bone or pelvis. It forms the upper part of the pelvic girdle and contributes to the acetabulum, the socket of the hip joint.
Articular Surfaces: The articular surfaces of the sacrum and ilium are covered with cartilage and form the synovial joint of the SI joint. These surfaces have irregular ridges and depressions that interlock to provide stability while allowing for limited movement.
Interosseous Ligaments: Several strong ligaments connect the sacrum to the ilium, providing stability to the SI joint. These ligaments include the anterior sacroiliac ligament, posterior sacroiliac ligament, interosseous sacroiliac ligament, and iliolumbar ligament.
Sacrotuberous Ligament: This strong ligament connects the sacrum to the ischial tuberosity (the bony prominence of the pelvis) and plays a role in stabilizing the SI joint.
Sacrospinous Ligament: Another ligament that connects the sacrum to the ischial spine (a bony projection on the pelvis), contributing to the stability of the SI joint.
7. Muscles: Several muscles surround the SI joint and provide dynamic stabilization. These muscles
include the piriformis, gluteus maximus, gluteus medius, erector spinae, and multifidus muscles.
8. Synovial Capsule: A fibrous capsule surrounds the SI joint, enclosing the synovial cavity and containing synovial fluid to lubricate the joint surfaces and reduce friction during movement.
These anatomical structures work together to provide stability and support to the SI joint while allowing for limited movement necessary for activities such as walking, running, and weight-bearing. Dysfunction or injury to any of these structures can lead to SI joint pain and dysfunction.
Common Risk Factors:
Several factors can increase the risk of developing sacroiliac (SI) joint pain. These include:
Trauma or Injury: Direct trauma to the pelvis, such as a fall or motor vehicle accident, can damage the SI joint and surrounding structures, leading to pain and dysfunction.
Pregnancy and Childbirth: Hormonal changes during pregnancy, particularly the hormone relaxin, can loosen ligaments and increase joint mobility to prepare for childbirth. This increased mobility can contribute to SI joint instability and pain, especially in the later stages of pregnancy and during childbirth.
Joint Dysfunction: Abnormalities in the structure or function of the SI joint, such as sacroiliitis (inflammation of the SI joint), sacralization of the lumbar spine (fusion of the sacrum with the lumbar spine), or transitional lumbosacral anatomy, can predispose individuals to SI joint pain.
Arthritis: Inflammatory conditions such as ankylosing spondylitis, psoriatic arthritis, or osteoarthritis can affect the SI joint, leading to pain, stiffness, and decreased mobility.
Gait Abnormalities: Irregularities in walking or running mechanics, such as leg length discrepancies, pronation or supination of the feet, or altered biomechanics due to previous injuries, can place increased stress on the SI joint, leading to pain and dysfunction.
Hypermobility or Hypomobility: Excessive mobility (hypermobility) or restricted mobility (hypomobility) of the SI joint can predispose individuals to SI joint dysfunction and pain. Hypermobility may result from ligament laxity or joint hypermobility syndromes, while hypomobility may occur due to stiffness or fusion of the joint.
Occupational Factors: Jobs or activities that involve repetitive movements, heavy lifting, or prolonged periods of standing or sitting with poor posture can increase the risk of SI joint pain by placing excessive stress on the joint and surrounding structures.
Muscle Imbalances: Weakness or tightness in muscles surrounding the SI joint, such as the glutes, hamstrings, hip flexors, and core muscles, can alter pelvic alignment and stability, leading to SI joint dysfunction and pain.
***The most common factor that we see here at PTSP! Dr. Yana’s “hip reset” addresses hip imbalance by assessing alignment in the supine position - by looking at alignment of knees and ankles, we can determine which direction your pelvis is tilted, and then can help re-align with isometric exercises (series of glute bridges, abduction, adduction, hip flexion)
Age: As individuals age, changes in joint structure, cartilage degeneration, and decreased muscle strength and flexibility can increase the risk of SI joint pain and dysfunction.
Genetics: Genetic factors may predispose individuals to certain conditions, such as ankylosing spondylitis or other inflammatory arthritis, which can affect the SI joint and contribute to pain and dysfunction.
Understanding these risk factors can help healthcare providers identify individuals who may be at higher risk for developing SI joint pain and implement appropriate prevention and treatment strategies.
Physical Therapy Interventions
Core Strengthening Exercises:
Posterior Pelvic Tilts: Lie on back with knees bent and press your lower back into the floor or mat. You should feel your pelvis rocking backwards during this exercise, and your core muscles engaging.
Bridge Exercise: Lie on your back with knees bent and feet flat on the floor. Lift your hips off the ground, engaging your glutes and core muscles. Hold for a few seconds, then lower back down. Repeat.
Plank Variations: Perform plank exercises to strengthen the core muscles, including the transverse abdominis and obliques.
Pelvic Stabilization Exercises: As mentioned earlier, the piriformis, gluteus maximus, gluteus medius, erector spinae, and multifidus muscles act as dynamic stabilizers to this joint, so it is essential that we maintain the strength here. Some of the common exercises that you will see us perform here in clinic are things like hip ER/IR's, double and single leg glute bridges, sidestepping, and quadruped "hip dips" respectively.
Stretching Exercises:
Piriformis Stretch: Sit on a chair and cross one ankle over the opposite knee. Lean forward slightly, keeping your back straight, until you feel a stretch in the buttocks. Hold for 30 seconds, then switch sides.
Hamstring Stretch: Lie on your back with one leg bent and the other straight. Use a strap or towel to gently pull the straight leg towards you until you feel a stretch in the back of the thigh. Hold for 30 seconds, then switch sides.
Manual Therapy Techniques:
Joint Mobilizations: A physical therapist may perform gentle manual techniques to mobilize the SI joint, helping to improve mobility and reduce pain.
Soft Tissue Release: Massage or soft tissue techniques can help relax tight muscles around the SI joint, such as the glutes and hip flexors.
Postural Correction:
Ergonomic Assessment: Evaluate and modify daily activities and workstations to ensure proper posture and alignment, reducing strain on the SI joint.
Body Mechanics Training: Teach proper lifting techniques and movement patterns to minimize stress on the SI joint during activities of daily living. Hip hinging, and adding resistance bands to legs for better hip abductor muscle engagement
Functional Training:
Hamstring Activation: If the "stork test" shows positive, that may mean your hamstrings are not activating. A common exercise we perform in the clinic is hip hinging with a hamstring RDL, where we teach you how to feel your hamstrings activating!
Dynamic Stability Exercises: Perform exercises that challenge balance and stability, such as single-leg stands or balance board exercises, to improve proprioception and control around the SI joint.
Gait Training: Analyze and correct walking or running mechanics to reduce impact and strain on the SI joint during weight-bearing activities.
Education and Self-Management:
Activity Modification: Educate the individual on modifying activities that aggravate SI joint pain and adopting strategies to protect the joint during daily tasks.
Home Exercise Program: Provide a personalized home exercise program with instructions and demonstrations for performing exercises independently to maintain progress between therapy sessions.
If you are dealing with SIJ pain, it's essential to work closely with a Physical Therapist to develop a tailored treatment plan that addresses your specific needs and goals. Consistent participation in a comprehensive rehab program can help alleviate pain, improve function, and prevent future flare-ups of your SI joint.
We hope this information helped you gain a better understanding of SIJ pain. To learn more about the other types/causes of low back pain, Follow and LIKE our Blog and subscribe to our email list. This is the first installment of our Spine Series and we have several more blogs coming on Low Back Pain.
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In Health,
The PTSP Docs
Dr. Brown, Dr. Bay, Dr. Yana
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