Sacroiliac pain SIJ

[bensims]

Hi

I have read through a few articles on this website and other related sites and am pretty convinced that I have a problem with my SIJ joint / surrounding structures. I experience pain on right PSIS, right groin and occasionally posterior right leg nerve pain particularly when I run and bear weight on my right leg when striding forward. Similarly I experience the same symptoms but worse when I cross country ski - again with my right leg forward in a weight bearing position. If I jump but equally land on two feet there is no problem and if i hop on the affected leg but maintain an upright posture with gluteals activated and trunk extended I do not experience pain. However if I attempt to hop forward on the right leg or any other direction other than directly up / down I experience the same pain. This is replicated if I attempt a lunge position with the right leg forward.

From this evidence it seems that when the right SIJ is in a position of torsion and anteriorly tilted it is not supported correctly and perhaps hypermobile. I have undertaken typical SIJ tests such as the Gaelsens and Fabers test(s) which prove positive findings on my right side - ie pain on psis, medial buttock area and right groin. However I have not found anyone who can properly diagnose my concerns and give me the correct set of exercises. I feel I need to strengthen the area and perhaps do this by mimicking the position I experience pain - ie when the right leg is bearing weight and slightly abducted from the left (in stride position). There are many differential diagnoses for this type of pain but with the information I have recieved I believe it the SIJ is involved and is the main cause of pain. Please can someone suggest something I am bored of swimming and want to get back to running.

Many thanks Ben
(Help me fellow physios)

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[nutskelly23]

Have you actually been assessed by a physio/sports rehab practitioner already? Who has told you that your right ilium is anteriorly tilted? Your SI joint relies on stabilisation for optimium transfer of loads ie hopping. This stabilisation comes from sorrounding muscles and ligaments If muscles around the pelvis/hip are not functioning properly ie 'tight' (over active), weak (under active) or lengthened this will lead to an structural imbalance around the pelvis and SI joint. This can lead to a functional leg length discrepancy. Anatomically your individual leg length's are probably similar. When you have muscular imbalance ie. shortened hip flexor musculature, this will pull your pelvis forward into anterior tilt. This in turn will affect the length of your leg in such movements as lunging (which brings on your pain) as your pelvis is unable to posteriorly rotate.
Your lumbo-pelvic ('core') stabilisers might also be weak. Your groin pain might arise from this. As the pelvis is unable to use it's 'core' muscles, it relies on the adductor muscles instead to stabilise during movement. The adductor muscles are not designed to stabilse the lumbo pelvic area as they do not attach to the lumbar spine, thus become over active and painful.
You need a full assessment on length of hip flexors, lateral rotaters ie piriformis (might be causing nerve pain down leg), adductors, abductors etc.
You also need strength testing on your lumbo pelvic stabilisers, glutes, adductors, hip flexors etc.
You need to be checked for functional leg length discrepancy.
As for exercises, you say when you purposely activate glutes, you can move pain free. You need to strengthen glutes (bridging etc) You also should look into Richard Jon Tigney exercises to teach your SI joint to move properly again. You probably need to lengthen right hip flexors (iliopsoas), piriformis and adductors.
Any particular reason or time when your pain come on? what mechanism?
SI joint pain is often insideous (gradual).
You will probably have to strengthen your core also. Maybe go back to basic's of activating your TA muscle while lying down and kneeling, learning to breath whilst activated. Work your way up to keeping it activated whilst moving functionaly.
Also get your lumbar spine properly checked out to rule out any reason for it to cause the pain.
There is an awful lot of if's and maybe's here as i cannot assess you myself.
Hope that helps a little.

[physiobob]

Yep, this one is a bit tricky to diagnose on a forum. You need to see someone with the skills in pelvic dysfunction. Often it is the opposite sides restriction that can cause the issue on the symptomatic side. Sometimes it is driven by the lumbar spine.

Suggest seeing someone with an interest in Muscle Energy Techniques (MET). This could be a physio, osteopath, chiropractor, Nordic therapist (where this all came from) etc. Many have the skills and many don't! So finding the right person is essential and I'd ask around for a personal recommendation.

[bensims]

Hi

Thanks for getting back to me:

in answer to the questions on the forum so far:

1. Yes I have seen two physios on the issue (neither sport orientated), 1 agreed the right sided SIJ was the problem (anterior rotation) and gave me side lying abductor strengthening exercises plus 1 leg bridges. The 1st exercise felt good (muscles warmed up) and that it was working the correct area - particularly glut medius. The 1 leg bridging did not feel like it isolated the area as well but I persisted. After 3 weeks or so it felt better but any attempt to run, stand with front foot forward and rotate torso or in supine lying bring right knee into hip flexion the pain was immediately back. Since then I have continued with these exercises but the pain is there inconsistently. (The other physio gave me core stability stuff which I do also)

2. Other times I get the pain is occasionally when I wake in the morning (only occasionally), walking up hills, and particularly when I stretch the adductors (right side) and them immediately put weight on my right foot - when the SIJ I assume is closing.

3. The pain is a complete mixture and has no patterns only that when I stretch my adductors (in a standing position placing my right foot on my left knee - like a flamingo!) then when I put my foot on the floor there is an immediate sharp pain turning to a dull pain which almost buckles the leg. At other times it is sciatic nerve pain, muscular aching in the QL area and the rest.


I think I am doing the correct exercises but it is hard to know the order and whether by stretching I am weakening the joint further and whether it would be possible to get strenghtening exercises which include weight bearing to mimick the position of injury. Thank you for your help and advice either way - I think its time to see a specialist.

[neuromuscular]

Dearbensims:

I guess that I would disagree that the SIJ dysfunction is your cause and is more the effect.

If you have done the usual asserssment and the right is in anterior rotation, what is the left? Is it anterior, neutral or posterior? Have you had an assessment of your pelvic angles with hip abduction? Using the landmarks of the PSIS to PSIS. ASIS to ASIS, and PSIS to ASIS (R&L) do assessments at the static postures of anatomical neutral, and the foot positions of 30 cm, 60 cm, 90 cm, to as wide as you feel comfortable directly lateral in the coronal plane.

WHat are your findings?

I have found that the adductor longus on left is hypertonic and causes the right innominate bone to go into anterior rotation in the majority. Forget the quads as an anterior rotator. The pain in your SIJ may be real and a mile high, but it probably is the effect and not the cause. Try treating the left adductor longus and pectineus. See if the right innominate bone becomes more neutral.

THere may be a left adductor magnus involved if you have posterior rotation of the left innominate bone. However, there would be pain in the left SIJ usually.

The next culprit to examine is the right illiacus and psoas. If your pain is deep and in the groin as indicated, I would suspect the illiacus first and then the psoas. Referred pain or paraesthesia from these can trigger feelings of stomach and intestinal discomfort as well as back pain. From the pain you describe, it would appear to be more of an illiacus injury than a psoas. Were you doing any activities which required you to lock your pelvis such as a tug of war or similar?

Have your breathing patterns been involved? The psoas anchors to the spine at the transverse processes. If it is hypertonic the serratus posterior inferior (R usually) and QL (left usually) can be involved. If you notice that you are more of a belly breather now than before, and your abdominal is gaining girth, you may not be able to rib breathe, because of the stress on the lower musculature of the back.

I have found that most ignore the pelvic angles and do not assess for innominate bone position. This has lead to a dismal success rate in low back and pelvic treatment.

Hope that this is of benefit to you.

Best regards,

neuromuscular.

[linbin]

hi all
till date i haven't came across any studies which strongly supports the "SIJ dysfunction concept".this joint has only minimal movement.as far as the studies suggests the muscle imbalance of the lumbopelvic area causes the "stuck SIJ joint perception".
once the cause is taken care of the movement around the area returns to normal and concurrent reduction of symptoms also takes place

[sheri]

HI Bensims

I have been struggling with the same problem for 18 months now. have had to go through rigorous examination to rule out (and was told by all practitioners involved that their diagnosis was the cause) FAI, MS, lumbar spine issues, reactive arthritis and psychological causes. from the beginning this pelvic imbalance (and i agree with the above thread that its more a muscle imbalance resulting in hypertonic painful muscles and ligaments than an "SIJ" issue) was my suspicion but it has taken so long to confirm and only now am i really getting adequate treatement and am improving slowly. what you need to take into consideration is that once you have had pain for more than 3 months, you body is in a "chronic pain" state. your wiring has been interupted and muscle function is hindered.
in the past i had done all the glut med strengthening, core stabilisation, pilates (i am a physio and pilates instructor so i would hope i knew what i was doing) and all the METS were performed on me etc....
the only thing to date which i s actually helping me is a combination of dry needling right down the spine to assist in releasing my extremely hypertonic erector spinae/multifidus and my opposite iliopsoas and adductor complex. its intense and painful at the time but has given me massive relief. i have only had two sessions (going for my third today) and have increased my quality of life from about a 3 to a 6. still not running and probably will never play soccer again (all the soccer injuries which i think have been a huge contribution to the problem). i also see an osteopath once a week on my doctors recommendation and she is doing her thing. before i had the needles it wasnt of much benefit but i think the combination of needles to re-wire my system and osteopathy and pilates is getting my strength and proprioception back gradually (i previously had no idea i was standing completely skew and could not lie in a straight line).
now the thing with needling is you have to find an expert. they are few and far between. many will just tap the needle in and leave it there. you need someone who can feel for the hypertonic muscle bands and dig into them til you get a twitch. its an awesome feeling!
as with all pain issues, address the emotional component. pain can cause us to feel useless and miserable and its worth talking it through with someone and see if there are any other contributing emotional factors. i know it sounds very text-booky and pathetic but its worth it.
last piece of advice i can give you is rest from activity until you are feeling at least 90% better. swimming is great for the lumbar spine but if your muscles are not working correctly you may still be over activating (especially adductors if doing breast stroke for example). running is a definite no no. as annoying as it is just take it easy!!
please keep us updated on your progress and hopefully we will both be up and running in good time.
take it easy

[BenMort]

I hope it's still not a problem for you but you should check out the strength of you hip internal and external rotators. I have a patient who has had back pain for 8 years! she has seen physios, osteopaths and personal ttrainers and has good TA activation and can do aerobic sessions at the gym and has good technique with bridging and planking but she had absolutely no strength in external and internal rotation at the hip. MET tehchniques can help to get these bad boys fired up again.Then just try to integrate them into more functional movements such asbridging then progress form there etc (If thats the problem).