The sacroiliac (SI) joint is formed by the articulation of the pelvis and the sacrum. Dysfunction of this joint can result from how the pelvis impacts on the sacrum or how the sacrum impacts on the pelvis. If the pelvis (ilium) is responsible for a fixated (immobile/stuck) SI joint, then it is called ‘iliosacral dysfunction’. If the sacrum is responsible, it is called ‘sacroiliac dysfunction’.
Recent interest in rehabilitation involving the SI joint may be attributed in large part to the fact that approximately 20-30% of low back pain and referred pain comes from the SI joint itself and/or the surrounding ligaments, muscles and other soft tissues involved in the functioning of the joint (Maigne et al, 1996, Schwarzer et al, 1995).
The concern in sports medicine relates primarily to the problems caused by the biomechanical changes inherent to the malalignment: specific sports injuries, impaired recovery from injury, and a failure of athletes to realize their full potential (Schamberger, 2002).
Sacral Motion and Dysfunction
When you forward bend, your sacral base moves in a posterior and slightly superior direction. When you backbend, your sacral base moves in the opposite direction, anteriorly and inferiorly. The anterior and posterior movement of the sacral base is called nutation and counternutation, but many practitioners use the terms anterior nutation and posterior nutation. “Nutation” means “nodding.”
Sacrums are also capable of sidebending and rotating. If there are no joint fixations, then this is what your sacrum does in walking (or running) as you shift your weight from one leg to the other. Most experts agree that the sacrum only exhibits ‘Type 1’ motion, meaning that sidebending and rotation are coupled to opposite sides (right rotated and left sidebent is known as ‘right torsioned’, left rotated and right sidebent are known as ‘left torsioned’). The combination of sidebending and rotation is also known as ‘torsion.’ When the sacral base is ‘right rotated’ the right sacral base is posterior in relation the the left sacral base, and vice versa. If, during an evaluation, you find that the sacral base is rotated (on either side) when you are in the neutral position (standing on two feet), then it is probably dysfunctional.
For instance, if an SI joint evaluation reveals that (in a neutral position) the sacral base is fixated on the right side, then you must determine whether the right sacral base is fixated in anterior or posterior nutation. Making the correct diagnosis is essential because you must treat the fixated side to correct the dysfunction. Treating the non-fixated side will be meaningless.
Why is this important to know? Because in cases of pelvic dysfunction, the side that hurts is often the side of the symptom (pain), but not the side that is fixated. Most practioners will try to treat the symptomatic side instead of the fixated side. There is a high probability that they will not be the same, and as stated previously, this work will be relatively meaningless.
Hip (Ilium) Motion and Malalignment
When we walk or run our hips rotate reciprocally in all three planes of motion. These are the ‘sagittal plane’ (front to back), the ‘coronal’ plane (side to side), and the ‘transverse’ plane (clockwise and counter clockwise around the vertical axis). In the sagittal plane, a type of hip rotation (malalignment) occurs as anterior or posterior rotation. In the coronal plane, a type of hip rotation occurs as upslip or downslip (this is also known as superior or inferior shear, respectively). In the transverse plane, a type of hip rotation occurs as inflare or outflare (this is also known as medial or lateral rotation, respectively).
If/when you discover an iliosacral fixation, at first you will only know the side of the fixation. You must then determine the type of malignment that is present (anterior/posterior rotation, inflare/outflare, upslip/downslip). Occasionally, an individual will present with a single malalignment. Typically, an individual presents with a combination of two malalignments. A triple combination is possible, but relatively rare.
Remember again, you must treat the fixated side…even if the opposite (contralateral) side is the symptomatic side. In the case of a single-type of malalignment, just go ahead and treat according to the appropriate technique. In the case of a combination of malalignment types, you must treat with the appropriate techniques(s), but also in the correct sequence. The correct sequence is critical because if your sequence is wrong, your work will be ineffective. But, if the sequence is correct, the first correction will be effective and the second malalignment will often correct itself automatically.
After you release the fixated side, you can treat the symtomatic side (especially if they are not the same side) to speed up the healing process on that side. This healing process will probably happen on its own, but may happen faster with treatment. Again, sequence is the key.
The clearer you are about what you are working on and the use of ‘direct’ techniques in treatment, the more effective the results will be. The use of indirect and ‘shotgun’ techniques, however, usually indicates less than a full grasp of the biomechanical descriptions and how to more precisely locate and treat the joint fixation.
Knowing what you are releasing in a client’s body adds to your clarity of purpose and makes you a more effective therapist. If you know what it is that needs to change, then the techniques you apply will be more effective than if you don’t know precisely what you are releasing.
Metaphorically, you must name your demons if you want to get rid of them. Knowing and naming what you are working on is an essential part of effective therapy.
Maitland, J. Spinal Manipulation… 2001. North Atlantic Books, Berkley, California.
Schamberger, W. The Malalignment Syndrome, Implications for Medicine and Sport. 2002. Elsevier Science Limited.
Maigne J-Y, Aivalikis A, Pfefer S. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996; 21: 1889-1892.
Schwarzer AC, Aprill CN, Boduk N. The sacroiliac in chronic low back pain. Spine 1995; 20:31-37.