Sacroiliac Dysfunction

What is Sacroiliac Joint Dysfunction?

The sacroiliac (SI) joint is a joint between the sacrum and the ilium, otherwise known as pelvic bone. Sacroiliac joint (SIJ) dysfunction is a lower back/pelvic condition that, in most cases, really should be termed "SI joint pain.” For the very rare case, SIJ dysfunction is actually dysfunction in the sense that it involves joint stiffness (hypomobility) or slackness (hypermobility) at the sacroiliac joints in the pelvis.

However, most people’s SIJ “dysfunction is actually just pain. Their pain is not normally caused by true “dysfunction” and changes in the SI joint movement because the SI only moves 2-4 mm. For this majority, their pain is caused by muscle dysfunction and nerve irritation in and around the SI joint. This muscle dysfunction and nerve irritation could be caused by injury, improper exercises, bad posture, etc.

SI joint pain and SIJ dysfunction are conditions that can affect both men and women of all ages, but are more common in females. Symptoms typically are present on one side of the back and affect 15% to 30% of patients with complaints of low back pain.¹ Physical therapists design individualized treatment programs to address SI joint pain and SIJ dysfunction based on the specific cause of each person’s condition and treatment goals.

There are two sides of the sacroiliac joint, and they normally work together. For the rare case of actual SIJ dysfunction, one side becomes stiff or slack, and they will not move together. This causes pain or muscle stiffness in the area. Pain is often made worse with walking and bending activities. Slackness in particular may occur during the menstrual cycle or pregnancy due to hormonal changes of relaxin that cause the ligaments to become lax.² In very rare cases, the SI joint is traumatized and moves. This traumatization occurs from traumatic injury, such as when a person falls and lands on one side of the body and alters the position of the joint. In the cases of people who have hypermobility syndrome throughout their entire body, or the more extreme version of this: Ehlers-Danlos syndrome, they may develop SI joint pain and/or SIJ dysfunction. Their hyper-flexible joints aren’t supported well enough by their muscles. SIJ dysfunction can also relate to some types of arthritis, including ankylosing spondylitis, an inflammatory process most often affecting the lower back, which may cause the vertebrae to fuse.³ SIJ caused by arthritis is especially complicated because the joint becomes what is termed an "irregular" joint because of the irregular shape of the surfaces between the ilium and the sacrum. This can be painful and does not respond well to mobilizing the joint, unlike other causes for SIJ dysfunction.

How Do Sacroiliac Joint Pain and Sacroiliac Joint Dysfunction Feel?

People with SI joint pain may experience:

• Pain that may be sharp, stabbing, or dull that is localized to one side of the pelvis/low back, groin, or tailbone.
• Pain that may radiate down to the knee.
• Pain with movements, including standing up from a sitting position, turning in bed, or bending/twisting.
• Muscle tightness and tenderness in the hip/buttock region.
• Pain with walking, standing, and prolonged sitting.
• Pain that is worse when standing and walking that eases when sitting or lying down.⁴

What Are We Actually Treating in Physical Therapy?

Since SI joint pain is usually due to a dysfunction of the muscles, nerves, and joints of the lumbar spine and hip, the areas around the SI joint and not the SI joint itself, we figure out which of those structures are irritated or not functioning properly and treat those. Your physical therapist will conduct a physical evaluation, focusing on your spine and hips.

Know that SIJ dysfunction is not detectable by a physical therapist looking at the joint or touching/ palpating the joint. If the joint is moving a little bit more than normal (remember that it has a number of ligaments around it and only moves 2-4 mm to begin with), this might or might not be painful for someone but is not something that a provider can feel. Therefore, if a patient exhibits signs that their SI pain might be the rare kind that includes SIJ dysfunction, then our physical therapists will first try to treat it with muscle strengthening. If it still doesn’t improve, then the patient will be referred to a surgeon because, if the joint is truly unstable, it probably won't ever respond well to strengthening. Before surgery, they’ll have their SIJ dysfunction confirmed through MRI or CT scan.

How Can a Physical Therapist Help?

Your physical therapist will design a targeted treatment program based on your evaluation and your goals for a safe return to exercise or daily activities. Treatment may include:

• Flexibility exercises: Stretching exercises may be prescribed to improve the flexibility of tight muscles. They may also help to improve movement in the spine and lower extremities and decrease stress at the sacroiliac joint during daily activities.
• Strengthening exercises: Strengthening helps to improve the stability of the muscles around the sacroiliac and spinal joints, which helps to reduce ligament strain and pain. These exercises focus on strengthening weak muscles, including the lower abdominal, pelvic floor, and buttocks muscles.
• Body mechanics: How you move and use your body for daily work and other activities can contribute to your SIJ dysfunction and/or pain. Your physical therapist will teach you how to improve your movements or body mechanics based on your specific daily activities. The physical therapist may also make recommendations to improve activities, including sitting and lifting and carrying objects.
• Braces: Your physical therapist may also recommend wearing a sacroiliac belt that is designed to provide support to the sacroiliac joints. It is used to provide stability during daily activities as your strength returns and flexibility improves. This modality is especially helpful for pregnant women.

Can SI Joint Pain and SIJ Dysfunction Be Prevented?

Fall prevention, the use of proper body mechanics (such as correcting your posture), and maintaining healthy activity levels are all ways that SI joint pain and SIJ dysfunction can be prevented. Adhering to appropriate strength and flexibility programs can maintain muscle mobility and strength to keep the area stable, especially when joint hypermobility is present. Your physical therapist can work with you to strengthen and stretch muscles around your joints to prevent conditions like SI joint pain and SIJ dysfunction from occurring.

Further Reading:

• Ehlers Danlos Syndrome

Sources:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707638/
2. https://spineconnection.org/back-pain-conditions/sacroiliac-joint-dysfunction/
3. https://www.hopkinsmedicine.org/health/conditions-and-diseases/ankylosing-spondylitis
4. https://www.cedars-sinai.org/health-library/diseases-and-conditions/s/sacroiliac-joint-dysfunction.html