When a client comes in for a massage to ease lower back pain, the cause needs to be determined. Several pathologies present with similar symptoms, and careful intake – as well as postural analysis – can help narrow down the culprit. Sacroiliac joint disorder (SJD) is one of the most common causes of lower back pain and can be difficult to both diagnose and treat by healthcare professionals.
Sacroiliac Joint Anatomy and Physiology
There are two sacroiliac joints (SIJ) in the human body. They are located at the junctions where the ilium (on pelvic bone) meets the upper lateral section of the sacrum (the bottom portion of the spine). The SIJs are L-shaped joints which move together as a single unit. The sacral surface of the joint is covered with hyaline cartilage; the ilial surface has fibrocartilage. While there are no muscles attaching directly between the sacrum and the ilium, the piriformis and gluteus maximus do cross the joint and connect the sacrum to the femur. The SIJ’s stability is reinforced by a combination of its shape as well as strong intrinsic and extrinsic ligaments.
Early in life, during infancy and toddler stages, the SIJs are gliding synovial joints with flat articulating surfaces. As the body ages and physical stress is placed upon them, they evolve into a more angular surface with fibrous joints. This stress is caused by walking upright and results from the torso’s weight as it transfers from the upper portion of the body, through the spine, into the pelvis and lower extremities.
The joints themselves have little movement, usually less than four degrees of rotation and two millimeters of shifting. The main function of the SIJ involves weight bearing and spinal function in the central, or axial, body. It also is a vital part of the movement involved with walking.
Signs and Symptoms of SIJ Dysfunction
SIJ dysfunction is sometimes hard to distinguish from other lower back problems, including piriformis syndrome and sciatic pain. However, there are several things typically associated with SIJ problems:
- A dull, unilateral (one-sided) low back pain which worsens when rising from a seated position, or climbing stairs.
- Pain may be referred to the hip, groin or upper portion of the leg.
- Pain and stiffness of the lower back, usually on one side, increasing with prolonged sitting or walking.
What Causes SIJ Dysfunction and Pain?
Like many joints in the body, the SIJs have cartilage which allows for some movement and acts as a kind of shock absorber between the articulating bones. If the cartilage wears away or is somehow damaged, causing the bones to rub directly against each other, osteoarthritis develops and results in pain. Other conditions affecting the SIJ include:
- Pregnancy – Giving birth also has a link to SIJ disorder. The hormone, relaxin, is released during pregnancy, easing the tension in ligaments as a preparation for delivery. This, combined with the added weight and altered gait associated with pregnancy, contributes to problems with the SIJ.
- Having one leg longer than the other can cause problems with the SIJ. This condition causes an abnormal walking pattern which, in turn, increases stress on the joint. This can often be addressed by the use of orthotics (special shoes or shoe inserts prescribed by a podiatrist).
- Trauma, such as falling hard on the buttocks, can often result in SIJ dysfunction.
- Various disorders that involve joint inflammation, such as gout, rheumatoid arthritis and psoriasis may also affect the SIJ, causing pain.
- Ankylosing spondylitis, an inflammatory arthritis of the spine, affects the SIJ. In early stages it is very painful but, as the condition progresses, the SIJ fuse together, resulting in no movement and no more pain.
The pain caused by the SIJ can result in the surrounding muscles tightening, splinting and spasming in an attempt to increase stabilization. Most often the affected muscles include the piriformis, the upper gluteus maximus, the erector spinae and transversospinalis.
Diagnosing SIJ Dysfunction
Only a physician or physical therapist can definitively diagnose SIJ dysfunction. They may use a combination of intake, palpation and X-ray or computed tomography (CT) scan. Magnetic Resonance Imaging (MRI) or bone scans may also be used in certain cases where a subtle fracture or bone abnormality may be suspected.
There are some passive stretches that can be done as a preliminary assessment by a massage therapist. If pain occurs, then SIJ dysfunction is likely the culprit and a physician referral should be considered.
- Straight Leg Raise – This is performed with the client in a supine position. The practitioner assists in flexing the hip joint with the knee fully extended. This is done one leg at a time. Pain associated with SIJ dysfunction may occur on either side.
- Nachlas Test – With the client in a prone position, the client’s knee is flexed and the ankle brought as close to the same-side buttocks as possible. This movement should not be forced if the client is unable to complete this assessment because of tight muscles in the thigh or hip, or if there is a significant knee injury.
- Yeoman’s Test – Similar to the Nachlas test, the client is in a prone position and the knee is passively flexed. The practitioner places his or her hand under the knee and actively lifts the thigh into extension, while stabilizing the same-side PSIS.
Reducing the Discomfort of SIJ Dysfunction
SIJ dysfunction is not a condition that can be actively prevented. It occurs as a result of normal aging, pregnancy, natural misalignment or inflammatory disease. Physical therapy can help to alleviate pain through the use of stretching and exercises that increase stability of the joint.
The pain of SIJ dysfunction can be reduced through the occasional use of anti-inflammatory medication and oral steroids prescribed by a physician. In extreme cases, surgery may be advised, but has shown mixed results. The client should refrain from any activity that increases pain, including prolonged periods of sitting.
Yoga, qigong and Pilates are all good exercise systems for strengthening the muscles surrounding the SIJ and can be an adjunct to other therapies.
Massage therapy can also help to reduce the pain associated with SIJ. It is especially helpful in reducing the pain of the musculature around the joint. Energetic modalities such as cranial-sacral therapy and polarity therapy can help to realign the body and reduce stress on the SIJ. Swedish massage techniques can help relax the muscles and improve circulation to the area. Positional release is a gentle manual treatment that may help to relieve the pain and discomfort of SIJ dysfunction by correcting imbalances of the musculoskeletal system.
Easing pain ranks right up there with stress reduction when it comes to the reasons a person seeks out a massage therapist. Learning about SIJ dysfunction and how its discomfort can be lessened is just one more tool to add to your resumé.