Sacroiliac Joint Dysfunction Rehabilitation Program

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Sacroiliac Joint Dysfunction Rehabilitation
Program

• By Kristen Knorr

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Anatomy

• This joints bony articulation is between the
  ilium and the sacrum.
• This is a synovial joint.
• Males have more stable S.I. joints due to the
  females pelvis being lighter, thinner and wider.
• Females ligaments are also more lax causing this
  joint to be much more stable in males.

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Anatomy

• This joint contains some of the strongest
  ligaments in the body.
• Iliolumbar
• Lumbosacral
• Anterior Sacroiliac
• Anterior Longitudinal
• Inguinal
• Sacrospinous
• Sacrotuberous
• Anterior Pubic

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Motions of the Sacroiliac Joint

• The direction of movement is based on the
  movement of the top of the sacrum, also known as
  the base.
• Sacral flexion or nutation occurs with trunk
  extension.
• Sacral extension or counternutation occurs with
  trunk flexion.
• There is rotation to the right and left.
• And a lateral tilt to the right and left.

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Physiology

• Shock Absorption
• Weight distribution from the lower to upper body.
• Transmits weight and rotational forces from the
  right to left side of the body.

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What is Sacroiliac Joint Dysfunction?

• S.I. dysfunction causes low back pain due to a
  malalignment between the sacrum and ilium.
• Injury can also be caused if a patient has
  excessive force on the area due to abnormal
  lumbar lordosis.
• The patient may feel as if this joint needs to be
  realigned.

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Causes of Injury

• Injury to the S.I. joint can occur from
  hypermobility or hypomobility caused by muscular
  imbalances, spasms, or loose ligamentous
  structures.
• A leg length discrepancy
• A fall onto the side of the pelvis or the
  buttocks.
• A misstep when walking or running.
• Excessive rotation.
• Pregnancy.
• Excessive Q angles.

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Most Commonly Involved Athlete's

• Soccer
• Football
• Basketball
• Gymnastics
• Wrestling
• Track and field

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Signs and Symptoms

• Sacroiliac joint pain is usually a unilateral
  pain that presents itself on the posterior
  sacroiliac spine (PSIS).
• Pain can range from a dull ache to a sharp pain
  that can refer down into the buttocks or upper
  leg.
• Pain or stiffness when sitting or standing for
  long amounts of time.
• Previous leg length discrepancy

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Special Tests

• S.I. Compression
• S.I. Distraction
• Yeoman
• Gaenslen
• Faber
• Long Sit

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Treatment

• Short Term Goals Reduce pain and inflammation,
  re-establish pelvic neutral, begin strengthening
  and stabilizing exercises while patient is in
  neutral position.
• Long Term Goals Return to normal gait and
  strength, have increased stability and control of
  the pelvic girdle, no pain or inflammation,
  return to normal ROM, return to play.

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Phase 1

• Short Term Goals
• Reduce pain
• Reduce inflammation
• Re-establish posture and neutral positioning
• Increase ROM
• Maintain cardiovascular endurance and strength.

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Phase 1 Pain Reduction

• To reduce pain and inflammation ice may be used
  for 15 20 minutes on the affected area.
• Interferential Stim may also be used with the ice
  to help promote pain reduction through endogenous
  opiates release.
• Quadripolar electrode placement.
• 80 120 MHz
• Vector scan on
• Patient should feel moderate to strong sensory
  level.

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Phase 1 Stretching

• Hamstrings
• Quadriceps/Hip Flexors
• Iliotibial Band
• Piriformis
• Erector Spinae/Low Back Musculature

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Phase 1 Joint Mobilization

• Muscle Energy Techniques
• Isometric Contraction
• Hold for 15.
• Grade 4 Joint Mobilization
• Heisman
• Inferior Glides.

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Phase 1 Stabilization/Strengthening

• Find pelvic neutral and maintain throughout all
  exercises.
• Superman
• On a stable surface
• Eyes open
• Lift arm and leg slightly off the table
• Can progress to eyes closed and lifting
  extremities further off the table.
• Hold each side for 3 seconds 15 times on each
  side
• If this is to too difficult the patient can begin
  supine.
  

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Phase 1 Stabilization/Strengthening

• Planks
• On a stable surface
• Hold for 15 seconds 3 reps
• Can increase time of hold as the person becomes
  stronger

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Phase 1 Stabilization/Strengthening

• Wall Squats
• Back against wall, do not let knees go past the
  ankle when bent.
• Hold at bottom of squat for 5 seconds.
• 15 reps
• Can progress to one leg.

• Bridges
• Begin on a stable surface
• Hold for 15 seconds, three times.
• Can increase the length of the hold as strength
  increases.

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Phase 1 Stabilization/Strengthening

• Crunches
• On a stable surface.
• Can begin with 3 sets of 15 and increase as
  needed.
• Can also progress to oblique crunches or
  bicycle/alternating leg and arm.

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Phase 1 Neuromuscular Control

• Balance
• Begin on stable surface with eyes open
• Progress to eyes closed and no shoes
• Start with tandem stance to one leg.

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Phase 1 Neuromuscular Control

• Sitting/Bouncing on a Swiss Ball
• Maintain pelvic neutral
• Continually correct posture and balance
• Progression can include closing the eyes or
  lifting one leg off the ground

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Phase 1 Cardiovascular Endurance

• The patient can begin using a stationary bike or
  elliptical as there pain subsides.
• An elliptical may be more comfortable because the
  patient may still have discomfort when sitting.
• 15 20 minutes.

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Phase 2

• In this phase regular stretching should continue
  as well as ice and stim for pain relief when
  necessary.
• Joint mobilizations should also be continued if
  needed.
• Cardiovascular endurance can also be kept the
  same as long as the patient is pain free.
• Short Term Goals Pain free, inflammation free,
  increase endurance, stabilization, and strength,
  increase/maintain ROM, continue postural and
  pelvic neutral education.

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Phase 2 Stabilization/Strengthening

• Superman
• This should be done with a swiss ball under the
  abdomen while keeping pelvic neutral.
• This can be held for 3 seconds. 15 reps on each
  side.

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Phase 2 Stabilization/Strengthening

• Planks with a swiss ball
• Feet or legs should be on the ball, not the toes.
• Patient may roll from a prone position on the
  abdomen, to where there feel comfortable on the
  ball.
• Hold for 15 x 3
• The patient may roll back onto the abdomen.
• Reps or time may be increased as needed.

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Phase 2 Stabilization/Strengthening

• Wall Squats
• Put a swiss ball inbetween the patients back and
  the wall.
• Control the speed.
• Hold for 5 seconds, 15 reps.
• Can progress to one leg.

• Bridges
• The patient will begin sitting on the ball, then
  rolling under the back, then slowly walk out
  letting the ball roll towards the head. They may
  stop when they feel comfortable.
• Hold 15 x 3. increase, 1 leg.

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Phase 2 Stabilization/Strengthening

• Swiss ball with thera-band
• The patient will sit on the swiss ball while
  holding a thera-band out in front of them.
• The clinician will pull the thera-band in an
  attempt to disrupt the patients balance.
• Record errors.

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Phase 2 Stabilization/Strengthening

• Crunches on a swiss ball
• Movements should be controlled
• 3 sets of 20
• Can increase amount as strength increases.
• Incorporate a medicine ball to be held above
  chest and progressing to overhead.

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Phase 2 Neuromuscular Control

• Balance
• On unstable surface.
• Can do with shoes off.
• Can progress to eyes closed.

• Squats
• Can be done on flat or round side of bosu.
• 3 sets of 10.
• Can progress to rhythmic stabilization in next
  stage.

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Phase 2 Neuromuscular Control

• Lunges on a bosu ball
• Knees should go to 90o bend.
• Keep neutral position.
• Hand on hips

• Quadrant Hops
• Begin in one direction, can switch direction or
  call out numbers, progress from 2 legs to one
  leg.
• Can close eyes or add theraband resisitance.

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Phase 2 Functional Activity

• Straight line jogging
• Lateral shuffle
• Jogging figure 8s
• Agility ladder
• Front
• Lateral
• jumps

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Phase 3

• Continue ice and stim for pain and inflammation
  as needed.
• Continue stretching program.
• Continue joint mobilizations if needed.
• Continue cardiovascular endurance in conjunction
  with cardio from functional activities.
• Short Term Goals Pain free, inflammation free,
  further increase endurance, stabilization, and
  strength, increase/maintain ROM, continue
  postural and pelvic neutral education, begin
  functional activities

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Phase 3 Strengthening/Stabilization

• Superman
• Can be done with a dyna disc under hands and
  feet.
• Hold for 3 5 seconds. 15 reps on each side.

• Planks
• A swiss ball under the legs and the patient is
  holding the bosu, flat surface up.
• 15 seconds x 3.

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Phase 3 Strengthening/Stabilization

• Wall Squats
• Swiss ball on back and standing on bosu or
  balance pad.
• Or weight could be given.
• 5 second hold x 15.

• Bridges
• Swiss ball under back and feet on the bosu or
  balance pads.
• Can progress to one leg.

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Phase 3 Neuromuscular Control

• Balance
• One leg, pad, catching a ball or holding a
  medicine ball.
• Hold for 1 minute x 3.

• Squats
• On a bosu holding a medicine ball or with weight.
• 3 sets of 10.

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Phase 3 Neuromuscular Control

• Lunges
• Either done on a bosu or on balance pads.
• Can add weight or a medicine ball to the activity.

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Phase 3/4 Functional Activity

• Sprinting
• Shuffle
• Figure 8
• Diagonal/Z
• Agility ladder
• 4 corner drill
• Sport specific
• Forward, backpedal, shuffle, carioca.

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Phase 3/4 Plyometrics

• Jump in place, jump forward, squat jump over a
  barrier.
• Lateral hops, lateral hops over a barrier,
  progress from 2 legs down to one.
• Barrier Hops increase height and length of hop,
  2 to1.
• Depth Jump different heights and patterns, 2 to
  1.
• Lunge Jump increase speed.
• Hurdles start with a jog and progress to sprint.

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Functional TestingReturn to Play

• Sprints
• Sprint figure 8
• Sprint diagonal/Z
• Explosive hops and jumps front to back, lateral.
• Sport specific tackling, throwing, swinging,
  catching, kicking.

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Article Information

• Formative Dynamics The Pelvic Girdle
• Studies show that up to 22 of low back pain is
  caused by the S.I. joint.
• Passive methods of stabilization include S.I.
  belts, tapings, prolotherapy injections to reduce
  pain in tendons and ligaments, and surgery in a
  small number of patients.

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Article Information

• Active methods include progressive strengthening,
  mobilizations, stabilization, and flexibility.
• Each treatment should begin with stretching,
  massage, and joint mobilizations.
• Followed by any modalities needed to assist
  proper muscular functioning before the
  strengthening phase begins.
• Studies showed that patient's who used this
  format overall had improved gait, ROM, alignment,
  and muscle strength.

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Summary

• S.I. joint dysfunction will present pain over the
  PSIS as well as down into the buttocks or legs.
• Pain can range from a dull ache to a sharp pain.
• Proper neutral pelvic positioning should be shown
  to the patient and maintained through all
  exercises.
• Strengthening should be focused on the core
  muscles to help stabilize the area around the
  joint.

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Summary

• Rehabilitation programs for this injury should
  include flexibility, mobilization, strength,
  stabilization, and functional activities to fully
  prepare the patient for return to play.

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Questions?