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The Symptomatic SI Joint Clinical Examination, Diagnosis and Treatment

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The Symptomatic SI Joint Clinical Examination, Diagnosis and Treatment Physical Therapy CEU The Symptomatic SI Joint Clinical Examination, Diagnosis and Treatment 1 Genne’ DeHenau McDonald PT • 28 years clinical experience (PT Degree Oakland University/Michigan State University) • Former Adjunct Faculty and Clinical Lecturer • University of Florida DPT Program • Former Faculty Herman and Wallace Pelvic Health Institute • Publications • Musculoskeletal LBP During Pregnancy • Piriformis Syndrome • Co-Author and Editor Original Gynecological Manual SOWH • APTA Member/SOWH Member since 1989 • Speaker for SOWH, SUNA • Program/Project Manager Medical Affairs SI-BONE Continuing Education Credits Website - http://www.questionpro.com/t/AKQvQZbCqQ **Certificates will be e-mailed the first and third week of the month after completion of survey **Please check junk mail folder Questions: Genné McDonald – Program/Project Manager - SI-BONE [email protected] 352-219-4286 Confidential & Proprietary 3 Course Objectives 1. Understand the prevalence of SI joint pain. 2. Review anatomy and biomechanics of the SI joint. 3. Review the integrated model of SI joint function. 4. Understand the relationship between the lumbar spine, SI joint and hip. 5. Review subjective history for patient with SI joint pain. 6. Correctly perform SI joint provocation testing 7. Review SI joint rehabilitation. 4 Prevalence of SI Joint Pain Is the SI Joint truly a problem? 15-30% 32-43% Component of chronic LBP Symptomatic Post-Lumbar Fusion 30.0% 27.0% 22.6% 18.5% DePalma – Pain Med 2011 14.5% 32% Katz 2003 35% Maigne 2005 43% DePalma 2011 Bernard Schwarzer Maigne Irwin Sembrano 40% Liliang 2011 1987 1995 1996 2007 2009 5 SIJ & Adjacent Segment Degeneration1,2 75% of post-lumbar fusion patients showed SI joint degenerative changes on CT scan 5 years after vs. only 38% age- and gender-matched controls without prior lumbar fusion Ha et al. 2008 Lumbar fusion leads to increases in angular motion and joint stress at the SI joint Ivanov et al. 2009 1. Ha – Spine 2008 2. Ivanov – Spine 2009 6 Anatomy Sacroiliac Joint Articular Surface 7 Anatomy Anterior Ligaments Posterior Ligaments 8 Biomechanics Nutation Nutation Sacral base movement anteroinferior Counternutation Sacral base movement posterosuperior Translation Linear motion; motion in any one direction Counternutation Forst 2006 9 SI Joint Motion Multi-planar motion – Simultaneously rotate and translate through 3 axes of motion Motions (<4° in any plane) – Nutation / Counternutation • Primary motion Males: 1 - 2° Females: 2 - 4° Sacral Translation – (A-P motion) up to 1.6mm Sturesson 1989 10 Integrated Model of SI Joint Function • Describes effective transfer of force and load across the SI joint from the lower extremities to the spine. Snijders & Vleeming 1993 • Requires a stable core (lumbar spine, pelvis and soft tissues) • 3 Components of Functional Stability Passive (form closure) Active (force closure) Neuromuscular Control (motor control) Panjabi 1992 11 The Integrated Model of SIJ Function Components Form Closure/Structural Motor Control: Nervous system Integrity: The shape of the coordination / co-activation of sacrum and the integrity of deep stabilizing muscles the supporting ligaments (onset, duration, timing) contribute to SI joint stability Snijders 1993, Hodges 1996, Richardson 2002 Lee 1998, Vleeming 1990a, Vleeming 1990b Force Closure/Joint Compression: The external dynamic forces created by Core muscles should contract contraction of the stabilizing before load reaches the low muscles and their fascial and back and pelvis to prepare the ligamentous attachments system for impending load. Lee 1998, Vleeming 1990a, Vleeming 1990b 12 Form Closure Osseous Structures – Macro, Micro Supporting Ligaments 13 The Integrated Model of SI Joint Function: Force Closure – Local Muscles Local System: contracts prior to upper/lower limb movement regardless of direction Hodges 1997, 2003; Hodges & Richardson 1997; Hodges 1999; Moseley 2002,2003 Local Core Muscles • Transversus Abdominus • Multifidus • Pelvic Floor Muscles • Diaphragm – More research being done on other contributing muscles 14 The Integrated Model of SI Joint Function: Force Closure – Global Muscles Global System: Contracts later and is direction dependent Radebold 2000, 2001; Hodges 2003 Vleeming’s slings: Large Muscle Groups and their Fascial Connections – Posterior Oblique System – Anterior Oblique System – Deep Longitudinal System – Lateral System Radebold 2000, 2001; Hodges 2003 15 Thoracolumbar Fascia & Paraspinal Muscles Caudal part of the TLF, in combination with efficient paraspinal muscles, plays major role in force closure of SI joint Macintosh & Bogduk – Spine 1993, Vleeming – Spine 1995 16 Motor Control • Optimal force closure of the SI joint • Studies showing alteration of muscle activation patterns in low back, groin, and SI joint pain populations – TrA Delayed in LBP Hodges & Richardson 1996 – TrA Delayed in Groin Injuries Cowen 2004 – Altered Motor Control with SI joint Pain O’Sullivan 2002 • Timing, sequence and amplitude of muscle firing – Afferent input from receptors in joints, ligaments, fascia and muscles – Efferent response of central and peripheral nervous systems Hodges 2003 17 Evaluation of the Patient with Sacroiliac Joint Pain 18 Can we diagnose SI joint pain? • Common pain patterns from multiple conditions – Spine (stenosis, facet, spondy, disc herniation, DDD, etc.) – SI Joint – Hip (OA, FAI, early AVN, etc.) – Pelvis (Glut tear, piriformis, pelvic floor) • Imaging not routinely helpful • History and Physical Examination − Provocative maneuvers Laslett 2005, Szadek 2009 − SI joint ROM & Position testing not reliable Freburger 1999, Robinson 2007 • Diagnostic Injection 19 Lumbar Spine – SI Joint – Hip Pain Referral Patterns Isolated Spinal Stenosis SI Joint Hip Pathology Buttock common Buttock, PSIS (94%) Buttock pain (71%) Groin uncommon (except L1, L2) Groin not uncommon (14%) Thigh and Groin (55%) Lower extremity common Lower extremity common (28%) Knee or below (47%) Lateral hip – common Lateral hip & thigh common Lateral hip – common Lumbar region common Lower lumbar region (72%) Lumbar pain uncommon Devin – JAAOS 2012 Vanelderen – Evid Based Med 2010 Devin – JAAOS 2012 20 Potential Causes of SIJ Pain: Traumatic • MVA: Foot on Brake • Slip and Fall • Lifting and Twisting • Traction Injuries 21 21 Potential Causes of SI Joint Pain: Gradual Onset • Laxity of the SI joint / Pregnancy • Repetitive Forces on SI joint and Supporting Structures • Biomechanical Abnormalities – Leg length inequality – Pelvic obliquity/scoliosis – Iliac crest bone graft • Adjacent Segment Degeneration – After lumbar spinal fusion • Post Infection Degeneration 22 22 Hip and Adjacent Segment (SI Joint) Hip and SI Joint 42% Hip OA 76% (25/33) of patients 45% Subchondral cyst with symptomatic SI joint pathology had at least one 21% Retroversion abnormal finding on hip 12% Lateral CE* angle >40% radiograph 47% Coxa profunda A significant number met the strict 33% Cam impingement diagnostic criteria for FAI. *Center Edge Morgan 2013 23 Elements of the Diagnosis Positive Positive SI Joint Subjective Provocative History Testing Lumbar Spine Positive Response to and Intra-articular Hip Exam Injection 24 History and Complaints HISTORY COMPLAINTS • When did the pain start? • Lower back pain • Prior trauma • Sensation of numbness, tingling or weakness – A fall on the buttock • Pelvis / buttock pain – Car accident (T-bone, rear-end, head-on) • Hip / groin pain – Lift/Twist • Feeling of leg instability, buckling, or giving way – Other • Disturbed sleep patterns • Prior lumbar fusion • Disturbed sitting patterns (unable to sit – Prior iliac bone graft harvest for long periods, on one side) • Pregnancy • Pain going from sitting to standing 25 25 History: SI Joint Pain Presentation Pain Diagram • Pain in buttock and posterior thigh – Usually not midline – Usually below L5 – At or lateral to PSIS – Occasionally groin • Secondary pain in lateral thigh, groin, and/or lateral calf Fortin 1999 26 26 Exacerbating Activities Pain with Transitional Motions - Supine to painful side - Sit to stand - Rolling over in bed - Getting in /out of bed Pain while Stationary - Sitting on affected side Unilateral Weight Bearing - Prolonged standing/sitting - Putting on Socks/Shoes - Ascending/Descending Stairs - Getting in and out of Car - Prolonged Walking (85% of gait cycle is single leg stance) Janda 1983 Sexual Intercourse 27 27 Relieving Activities • Bearing weight on unaffected side • Lying on unaffected side • Manual or belt stabilization 28 28 Lumbar Spine – Hip – SI Joint Physical Examination 29 Assess Lumbar Spine: Facet Joint Pain • Incidence 10-15% in patients with chronic LBP Saravanakumar 2008 • Low back pain from the facet joints: radiates down into the buttocks and posterior thigh. • Clinical Findings – Point tenderness overlying the inflamed facet joints – Loss in spinal muscle flexibility (guarding) – More discomfort leaning backward than forward. • No history findings or examination maneuver has been found to be unique or specific to this entity Kayser 2008, Cohen 2007, Jackson 1998 30 Assess Lumbar Spine: Disc-Related Pain The McKenzie Procedure • More accurate than MRI in: – Differentiating discogenic from non-discogenic LBP – Differentiating contained from non-contained discs (Donelson 1997, 1990) • Measures patient's symptomatic response to repeated end-range movements • Discogenic pain is associated with centralization with repeated end range movements (Young 2003, Hancock 2007) • Most common direction of testing that
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