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SACROILIAC JOINT

of those muscles assumed, or assessed, to be over- or perseverantly active, such as post-isometric contraction/ relaxation, reciprocal inhibition, or it may involve the use of some other type of inhibition technique such as posi- tional release, functional technique, dry-needling, releases, soft-tissue work etc.

After each application of technique, a reassessment of active and passive movement and position is made to assess the requirement for further treatment.

As elements of the dysfunction are cor- rected by manual therapy it is common to see improvements in the subject’s ability to perform active straight leg raise. This implies that joint stability has improved.

Treatment continues until normal movement is restored to the active movement tests and the active straight leg raise is optimised as far as possible.

As bilateral dysfunction is common it is likely that both sides will require inter- vention.

Once the active movement and active straight leg raise tests are optimised, this biomechanical improvement is equated to symptomatic improvement by re-testing the established aggravating activities. This establishes the relationship between these biomechanical markers and the patient’s condition.

SUPPORTIVE STRATEGIES AND REHABILITATION Long-term improvement is usually depen- dant on continued treatment and good rehabilitation and can be helped or accel- erated by certain supportive strategies. The sacroiliac stabilisation belt is the most specific of these strategies. The belt is placed so that it crosses the SIJ and tightened to produce joint compression. The need for the belt, and correct posi- tioning of its application, is confirmed by improvements in the active straight leg raise test and/or pain on movement (6,9). As well as its pain-relieving effect, the belt should make re-injury much harder and it also appears to improve local sta- biliser recruitment.

This makes the SI belt a very useful reha- bilitation tool. With the belt on, rehabil- itation exercises appear to be executed with improved precision and isolation,

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and the recruitment of these muscles continues to be enhanced as the patient performs their day-to-day activity ie. context-specific functional retraining. The patient may wear the belt fairly con- tinuously at first, depending on their presentation, but should wean off it as their muscle function improves. It is a self-limiting intervention ie. once good dynamic stability has been restored, the belt no longer helps and is no longer needed.

Certain taping techniques also appear to be helpful. Tape can be used instead of the SIJ belt to compress the joint - this is often a better strategy on the sports field as it is less likely to move, and either rigid or elastic tape can be used depending on need. Gluteal taping, as described by McConnell, often appears to assist gluteal recruitment, or at least seems to improve balance and lower-limb function.

Rehabilitation aims to improve the recruitment and timing of both the super- ficial and deep muscles that play a role in controlling the movement of the SIJ and pelvis as a whole. As there is continuity between the stabilisers of the SIJ, trunk and hip the whole area must be consid- ered. Rehabilitation will be covered in more detail in the adjoining article.

Treatment to the pelvis can be of assis- tance in a number of situations and for a number of presentations, but it must be realised that there are very few circum- stances in which the pelvis can be treat- ed in isolation. Treatment of the sacroili- ac joint and pubis should be incorporated into the overall management of the pre- senting signs and symptoms. Most com- monly, of course, this means that the pelvis is treated in continuum with treat- ment to the lumbar spine and hips, but other areas and components to the presiding dysfunction should always be considered.

THE AUTHOR Howard Turner holds a physics degree from Melbourne University and a physio- therapy degree from Latrobe University, Melbourne. He has been living in the UK since 1991, has a private practice in Wilmslow, Cheshire and acts as a consul- tant physiotherapist to the English Institute of Sport. He lectures on the University College London Masters in

Physiotherapy, the University of East London Masters in Sports Medicine and is the author of ‘The Combined Approach to the Sacroiliac Joint’, a post-graduate train- ing course for physiotherapists.

References 1. Meisenbach RO. Sacroiliac relaxation; with analysis of eighty-four cases. Surgery Gynaecology and Obstetrics 1911;12:411- 434 2. Adams, Michael A, Bogduk N et al. The Biomechanics of Back Pain. Churchill Livingstone 2002. ISBN 0443062072 3. Schwarzer MD, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995;20:31-37 4. Indahl A et al. Sacroiliac joint involvement in activation of the porcine spinal and gluteal musculature. Journal of Spinal Disorders 1999;12(4):325-330 5. Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 2003;28(14):1593-1600 6. O’Sullivan PB et al. Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine 2002;27:E1-E8 7. Snijders CJ, Vleeming A, Stoeckart R. Transfer of lumbosacral load to iliac bones and legs. Part 2: Loading of the sacroiliac joints when lifting in a stooped posture. Journal of Clinical Biomechanics 1993b;8:295-301 8. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine 2000;25(3):364-368 9. Vleeming A, Mooney V, Snijders CJ et al. Movement, Stability and Low Back Pain. Churchill Livingstone 1997. ISBN 0443055742 10. Poole-Goudzwaard AL, Vleeming A, Stoeckart R et al. Insufficient lumbopelvic sta- bility: a clinical, anatomical and biomechanical approach to “a-specific” low back pain. Manual Therapy 1998;3(1):12-20 11. Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine 1994;19(11):1243- 1249 12. Maigne J-Y, Aivaliklis A, Pfefer F. Results of sacroiliac double block and the value of sacroil- iac pain provocation tests in 54 patients with low back pain. Spine 1996;21(16):1889- 1892

13. Fortin JD, Ponthieux B, Pier J (1994b): Sacroiliac joint: pain referral maps upon apply- ing a new injection/arthrography technique. Part II: clinical evaluation.

Spine

1994b;19(11):1483-1489 14. Lee D. The Pelvic Girdle. An approach to the examination and treatment of the lumbo- pelvic-hip region. Churchill Livingstone 1999. ISBN 0443058148 15. Mens JM, Vleeming A, Snijders CJ et al. A clinical approach to the load transfer function of the pelvic girdle. In: Proceedings from the Second Interdisciplinary World Congress on Low Back Pain and its Relation to the Sacroiliac Joint. La Jolla, November 9-11 1995.

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