In the second of a two-part series, David Joyce sets out a treatment strategy for sacroiliac

joint (SIJ) dysfunction

Last month, we looked at the way the well-functioning sacroiliac joint achieves the stability we
need to run and jump, through the mechanisms of ‘form closure’ (anatomical fit) and ‘force
closure’ (active compression provided by the neuromuscular system). We covered various
clinical signs for sacroiliac joint (SIJ) dysfunction and pain(1), and looked at two assessment
tests in particular – the active straight leg raise and the stork test. In this second article, we
concentrate on treatment strategies for sacroiliac joint (SIJ) pain.

Acute phase

The initial aim of the therapist will be to reassure the client and protect the injured part to
ensure optimal healing. It can be very helpful to use an outcome measure at the outset,
repeated at the end of rehab, to give both therapist and client measurable assessments of the
programme’s success. There is no single perfect tool for sacroiliac joint (SIJ) outcome
measurement, but the Oswestry Disability Index or the Quebec Back Pain Disability Score are
both good (see box overleaf).

Education: As always, it is important to educate the client about the nature of the problem, in
order to reduce their anxiety – and therefore their pain levels. It will also help with their
compliance. In the case of sacroiliac joint (SIJ) pain, the therapist should explain the anatomy
of the joint, so that the client starts to understand why they get pain when ascending stairs or
landing after a tennis serve, and why they may need to cease running and jumping for the
time being.

Pain relief: Manual therapy techniques that reduce the stretching stress on the pelvic
ligaments can be very effective for relieving pain. Two of the most commonly provoked
ligaments are the sacrotuberous ligament and the long dorsal sacroiliac ligament. The
sacrotuberous ligament is tensioned when the pelvis is tilted posteriorly. Anterior tilting of the
pelvis on a therapy ball can help to quieten this one down. The long dorsal sacroiliac ligament
is tensioned in anterior pelvic tilt. Stepping up on to a chair (thereby fixing the hip in flexion)
with active posterior pelvic tilt and trunk flexion will help decrease the tension on this
ligament and reduce pain. These are lovely exercises for the client to complete at home.

Acupuncture can be very useful in the acute stage and the application of a cold pack over the
sacrum is often helpful as it can slow down the conduction of nociceptive information through
the nerve fibres. A pelvic belt or rigid sports strapping may provide some compressive
support. The therapist may also need to liaise with GP or specialist for advice on analgesic
prescription.

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Stretching: Muscle spasm form part of ‘body logic’. The body seeks to augment its stability in
the damaged area by increasing the tone of some of the longer muscles. Unfortunately these
muscles are physiologically designed as prime movers or ‘accelerators’ and tend to spasm if
used in a dual role of movement and support. This muscle spasm can make the client’s pain
experience more miserable, but if the injury is acute or traumatic, sometimes getting rid of
this spasm can be disadvantageous, as it may be the only basis of support they have. I tend to
leave the stretching and muscle release until the situation has settled down a bit.

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Sacroiliac joint (SIJ) dysfunction is often found in combination with lumbar spine problems.
The lumbar spine must be assessed and any dysfunction addressed. That’s a different ball
game and is beyond the scope of this article.

Breathing: We know that sacroiliac joint (SIJ) dysfunction can alter breathing patterns(2). It
appears that the brain has trouble coordinating respiration and pelvic support when sacroiliac
joint (SIJ) pain is present. Thankfully the brain devotes its resources to the task of keeping
our lungs active. We, as clinicians, need to address the coordination of breathing with
maintenance of pelvic stability.

We need to encourage the normal breathing pattern and limit the use of accessory respiratory
muscles: look for the clavicles rising too much during quiet breathing or breath-holding when
moving the limbs. The sacroiliac joint (SIJ) client will often alter their breathing pattern when
trying to complete some of the more challenging tasks later on in their rehab – another
important cue to look out for.

Motor control retraining: Motor control involves low threshold activation and endurance
training of local and global stability muscles. The most important local stabilisers are:

* transversus abdominis (whose fibre orientation is highly specific for compressing the SIJ)

* pelvic floor slings

* internal obliques

* deep psoas major

* multifidus.

These muscles provide the ‘base for the crane’. If the base is wobbly, the crane cannot lift
much (hence the positive ASLR test as discussed in Part 1).

Research shows that these muscles are not failing to contract, but that they lose their
anticipatory firing ability to prepare the pelvis for impending load(2). It is this anticipatory
function that must be restored.

There is debate about the right moment to start stability retraining. Some believe that the loss
of lumbopelvic muscle contraction is the result of pain and that it is folly to begin instructing
the client before there is adequate pain relief. My own belief is that this aspect needs to be
broached with the client early and reinforced in subsequent sessions.
I also believe the client needs to leave their first treatment session with some feeling of
muscular control of their wayward pelvis. It is highly likely that they will be inefficiently
bracing to begin with, but this can be refined subsequently. It’s important to tell the client that
these kinds of low-threshold lumbopelvic control exercises are unlikely to fix their problem
instantly, but they provide the foundations for later progress.

Sub acute phase

Once the pain has died down, trigger points can be safely addressed. Massage and the
application of a heat pack over localised areas of muscle spasm (for example, hamstrings and
quadratus lumborum) can help. The client can be sent home with a programme of stretches,
which may include any or all of adductor, hamstrings, hip flexor, gluteal and quads stretches.
Not all muscles need to be stretched and it is possible for a muscle to be too long and
therefore force-inefficient. Let your assessment findings be your guide.

Muscle energy techniques: METs are very effective in correcting pelvic positional faults. They
rely on the phenomenon that muscles are at their most relaxed directly after they have
contracted. This can be used to advantage to subtly manually reposition a joint which was
mal-located. For example, a common feature of sacroiliac joint (SIJ) dysfunction is an
anteriorly rotated ilium, often maintained by the quadriceps. The MET for this is to get the
client gently to contract their rectus femoris isometrically against the therapist’s manual
resistance. This contraction is held for six to eight seconds and then relaxed. During the
relaxation, the therapist takes the opportunity to posteriorly glide the ilium into an
anatomical position. This can sometimes take several repetitions and needs to be followed up
with home stretches. The same technique can be used with many other pelvic alignment
faults.

Motor control: Once the client can cocontract their transversus abdominis, multifidis and
pelvic floor, while being able to breathe appropriately, it is time to move them on to more
challenging tasks, involving holding the contraction while moving their limbs. This can be
done in almost any position and can be further progressed by adding elements of speed and
resistance to limb movements, or by making the supporting surface less stable (with a therapy
ball or foam roller, for instance) to challenge their central control. When designing exercises,
the therapist should aim to get the client into a functional weightbearing position as soon as
possible.

Resistance training: This needs to be broken down into its components of strength, power and
endurance. The training principle of specificity applies, and again, the therapist’s programme
design should reflect this. Use the guide below when designing a programme.

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There is no evidence that low-load training corrects strength deficits in the limbs or ‘core’
muscles; nor is there compelling proof that motor control training is a pre-requisite for
strength training.
Core strength training results in co-contraction of all regional muscles. It emphasises rigidity
rather than motor control and is an integral part of training to tolerate loaded activity. As such
it should be part of an integrated strengthening programme.

Starting strength training early works well(3), but given that the patient is likely to have
problems transferring vertical loads, initial training may need to be prone or supine, using
pulleys or resistance bands. Exercises such as the plank, side plank, lat pull downs and
resisted hip adduction all activate and strengthen key muscles that add to pelvic compression.

Late phase rehab

Progression: A gradual increase in vertical loading can be introduced as tolerated. This may
involve half lunges (eg, to 45 degrees) and step ups. The therapist should bring the client’s
attention to activation of their lumbopelvic supporting ‘slings’ as they perform these tasks.
This will help retrain the brain to an adaptive muscle pattern. As the client improves, the
complexity and load of these tasks can be increased. Incorporating resistance exercises that
combine arm and leg movement as well as trunk co-contraction replicates functional tasks
such as serving in tennis. This can be achieved by performing a step-up while simultaneously
performing a bilateral resistance band lat pulldown (see Figures 1a and 1b, p3).

Once the client is walking well and stairs are not a problem, we can start to increase the
vertical load. Gentle jogging can begin but if this is provocative, a stepper or cross trainer is a
useful intermediary.

Plyometric exercises that involve multijoint movements performed at speed comprise the end
stage of rehab and should only be started when the client is completely pain free and able to
run without difficulty. This could involve a variety of jumping and hopping tasks that
challenge the ability of the pelvis safely to transfer such high vertical loads.

Summary

Rehabilitation of the sacroiliac joint (SIJ) is still shrouded in mystery, but it doesn’t need to
be. If the presenting problem is assessed properly and treated along the same lines as for say,
an ankle or any other joint, you won’t go far wrong. The need to individualise the
rehabilitation is obvious. With a systematic plan, and an individualised treatment approach,
the scourge of sacroiliac joint (SIJ) pain will be defeated and you will have your client back at
squash, competing in the triple jump or just running around the block.

References

1. O’Sullivan PB, Beales DJ, Beetham JA, Cripps J, Graf F, Lin IB et al. (2002). ‘Altered Motor
Control Strategies in Subjects with Sacroiliac Joint Pain During the Active Straight-leg-raise
Test’. Spine 27, E1-E8.

2. Hungerford B, Gilleard W, and Hodges P (2003). ‘Evidence of Altered Lumbopelvic Muscle

Recruitment in the Presence of Sacroiliac Joint pain’. Spine28, 1593-1600.
Therapists prescribe core stability exercises to patients suffering from a variety of injuries,
especially those involving the back, groin, hamstrings and knee. But within the repertoire of
‘core stability’ there is a large range of exercises, the suitability of which will vary according to
the injury and therapeutic needs of each individual client. There are three major groups:

• those focusing on the recruitment of the small deep-lying stabilising

muscles, transversus abdominis and multifidus, often taken from clinical
Pilates
• static bodyweight exercises focusing on developing stability and/or
strength endurance in certain postures, and requiring co-contraction of
the small stabiliser and larger mobiliser muscles, such as the popular
‘plank’ exercise
• traditional dynamic strength exercises for the prime movers of the
trunk, often performed on the floor or Swiss ball.

Different therapists will make their exercise prescription choices in line with their clinical
preferences, but commonly patients will start with the recruitment orientated exercises and
progress to strength work once stability has been achieved and symptoms are progressing.

Sports medics, physiotherapists and strength and conditioning coaches also recommend that
athletes perform regular core stability or trunk strength exercises to prevent injury. The
rationale for prophylactic training is that increased recruitment of the stabiliser muscles and
increased strength of the prime movers will carry over into better posture and more control,
both in daily life and in sporting movements. Athletes tend to have a list of three to five ‘core
stability’ exercises targeting various muscles or positions that they are required to perform
regularly each week.

Whilst this prehabilative strategy is well intentioned, it has two limitations. The first is
behavioural. Core stability exercises can quite quickly become ‘bore stability’! It takes self-
discipline to do 20-30 minutes of the same exercises three or more times a week over a long
period. As a consequence, adherence to the preventive programme can be an issue. The
second limitation is physiological. The principles of specificity and progression apply to core
work in the same way as they do to any other body training. In my experience it is quite
common for an athlete to perform the same core routine over a long period and get very good
at four or five movements or ‘holds’. But teach the same athlete a new core exercise and they
will find it difficult, simply because it’s a new stimulus. The message is that progression and
variety are key to optimising benefits of a strengthening programme.

The scheme of ‘core training menus’, presented below and in forthcoming issues of Sports
Injury Bulletin, aims to overcome the problems of non-compliance and lack of challenge, and
provide a system where an athlete can follow a prophylactic or rehabilitative core stability and
strengthening programme using a wide variety of movements to maximise adaptations and
muscle groups trained.

It is designed for athletes who have developed basic transversus recruitment skills and are
familiar with a number of core exercises. The scheme offers a challenging programme, which
covers all the trunk and pelvic muscles and runs from basic recruitment to very advanced
strength movements.

The training system contains 10 exercise menus, each menu using a single piece of training
apparatus. A menu contains four to eight exercises, which between them target most trunk
and pelvic muscles. Some of the exercises involve resistance, some bodyweight, some are
simply about recruitment.

Within the menu, the difficulty of exercises varies, and some menus are very advanced (and
therefore not within the competence of all athletes). Coaches, therapists and athletes should
set the number of sets and repetitions for each exercise according to the usual principles.

The therapist or coach should select the most relevant menus, which the athlete should use in
rotation. Thus, if the athlete is using eight menus and doing four units of core training per
week, over the course of a fortnight they will perform each menu once. This will ensure that
the athlete works all the muscles in a variety of ways, using different pieces of equipment.

Menu 1: Floor, static

The aim of this menu is to develop a basic level of lumbar and pelvic stability working front,
rear and side muscles of the trunk. It can also be used as a maintenance dose of training for
intermediate to advanced level athletes

The plank

Overview A common exercise that requires good abdominal strength and co-contraction of
the abdominal wall musculature to hold the lumbar spine and pelvis in correct alignment

Level Basic/intermediate

Muscles targeted
Rectus abdominis
Abdominal wall (TvA/internal obliques)

Technique Hold a straight body position, supported on elbows and toes. Brace the abs, and
set the low back in the neutral position, once you are up. Sometimes this requires a pelvic tilt
to find the right position. The aim is to hold this position, keeping the upper spine extended,
for an increasing length of time up to a maximum of 60 secs. Perform two to three sets. Keep
shoulders back and chest out, while maintaining the neutral lumbar position. This makes the
exercise considerably more challenging

Progression Lift one leg just off the floor; hold the position without tilting at the pelvis

Birddog’ or ‘Superman’
Overview Also recommended by McGill as a safe and effective exercise for the lumbar and
thoracic portions of the erector spinae muscle. This exercise also requires co-contraction of
the abdominal wall muscles to stabilise the pelvis

Level Basic/intermediate

Muscles targeted
Thoracic and lumbar portions of erector spinae

Technique Start with hands below shoulders and knees below hips. Set your low back into
neutral and brace your abs slightly. Slowly slide back one leg and slide forward the opposite
arm. Ensure that the back does not slip into extension, and that the shoulders and pelvis do
not tilt sideways. Hold, increasing the duration up to a maximum of 20 secs. Slowly bring
your leg and arm back and swap sides. Perform sets of 5-10, alternating sides after each hold

Progression None

‘Birddog’ or ‘Superman’

To develop a good level of strength endurance in the major trunk muscles. Overall the level of
these exercises is intermediate to advanced

Active straight-leg raise

Overview Requires a strong static contraction of the abdominals to stabilise the lumbar
spine against the load of the legs. It also requires good active range of motion of the
hamstrings

Level Intermediate/advanced

Muscles targeted
Rectus abdominis
Abdominal wall
Hip flexors

Technique Lie on your back with knees bent. Set your lumbar spine in neutral and brace the
abs. Lift one leg up straight in the air, ensure your back does not move. Lift the other leg up,
again keeping your back in place. (If the back cannot be stabilised during this movement, the
exercise is too advanced and more static transversus stability control work will be needed
first.)

Keeping one leg in the air, slowly lower the other down to the floor. Only go as far as you can
until you feel the lumbar spine start to move. Placing your fingers under your back will help
you to gauge when this happens. Keep bracing the abs and then lift the leg slowly back up.
Repeat with the other leg. Perform sets of 5-10 reps, alternating legs

Progression Lower and raise both legs together

Oblique crunch

Overview A good exercise for both the obliques and the abdominals

Level Intermediate

Muscles targeted
Rectus abdominis
Obliques

Technique Lie on your back with right ankle resting on left knee. Right arm is placed on the
floor out to the side. Keeping the right shoulder down, curl the left shoulder up to the right
knee. Crunch at the top and return slowly, under control. Perform sets of 15-30 reps on each
side in turn. Avoid ‘head nodding’ during the movement: keep head off the floor and look
forward throughout

Progression Hold a dumbbell in the hand by your head. Keep arm still so you are forced to
raise the dumbbell using your abs and not your arm