Sacroiliac joint (SIJ) pain refers to the pain arising from the SIJ joint structures. SIJ dysfunction generally refers to aberrant position or movement of SIJ structures that may or may not result in pain. This paper aims to clarify the difference between these clinical concepts and present current available evidence regarding diagnosis and treatment of SIJ disorders. Tests for SIJ dysfunction generally have poor inter-examiner reliability. A reference standard for SIJ dysfunction is not readily available, so validity of the tests for this disorder is unknown. Tests that stress the SIJ in order to provoke familiar pain have acceptable inter-examiner reliability and have clinically useful validity against an acceptable reference standard. It is unknown if provocation tests can reliably identify extra-articular SIJ sources of pain. Three or more positive pain provocation SIJ tests have sensitivity and specificity of 91% and 78%, respectively. Specificity of three or more positive tests increases to 87% in patients whose symptoms cannot be made to move towards the spinal midline, i.e., centralize. In chronic back pain populations, patients who have three or more positive provocation SIJ tests and whose symptoms cannot be made to centralize have a probability of having SIJ pain of 77%, and in pregnant populations with back pain, a probability of 89%. This combination of test findings could be used in research to evaluate the efficacy of specific treatments for SIJ pain. Treatments most likely to be effective are specific lumbopelvic stabilization training and injections of corticosteroid into the intra-articular space.
Corticosteroid Injection; Diagnostic Accuracy; Intra-Articular Injection; Lumbopelvic Stabilization Training; Pregnancy-Related Pelvic Girdle Pain; Sacroiliac Joint Dysfunction; Sacroiliac Joint Pain
Recently, the sacroiliac joint (SIJ) has gained increased attention as a source of persistent or new pain after lumbar/lumbosacral fusion. The underlying pathophysiology of SIJ pain may be increased mechanical load, iliac crest bone grafting, or a misdiagnosis of SIJ syndrome. Imaging studies show more frequent degeneration of the SIJ in patients with lumbar/lumbosacral fusion than in patients without such fusion. Using injection tests, it has been shown that SIJ pain is the cause of persistent symptoms in a considerable number of patients after fusion surgery. Recent articles reporting on surgical outcomes of SIJ fusion include a high percentage of patients who had lumbar/lumbosacral fusion or surgery before, although well-controlled clinical studies are necessary to assess the efficacy of surgical treatment. Taking these findings into consideration, the possibility that the SIJ is the source of pain should be considered in patients with failed back surgery syndrome after lumbar/lumbosacral fusion.
Sacroiliac joint pain; Lumbosacral fusion; Lumbar fusion; Pathophysiology
Effective stabilization of the sacroiliac joints (SIJ) is essential, since spinal loading is transferred via the SIJ to the coxal bones, and further to the legs. We performed a biomechanical analysis of SIJ stability in terms of reduced SIJ shear force in standing posture using a validated static 3-D simulation model. This model contained 100 muscle elements, 8 ligaments, and 8 joints in trunk, pelvis, and upper legs. Initially, the model was set up to minimize the maximum muscle stress. In this situation, the trunk load was mainly balanced between the coxal bones by vertical SIJ shear force. An imposed reduction of the vertical SIJ shear by 20% resulted in 70% increase of SIJ compression force due to activation of hip flexors and counteracting hip extensors. Another 20% reduction of the vertical SIJ shear force resulted in further increase of SIJ compression force by 400%, due to activation of the transversely oriented M. transversus abdominis and pelvic floor muscles. The M. transversus abdominis crosses the SIJ and clamps the sacrum between the coxal bones. Moreover, the pelvic floor muscles oppose lateral movement of the coxal bones, which stabilizes the position of the sacrum between the coxal bones (the pelvic arc). Our results suggest that training of the M. transversus abdominis and the pelvic floor muscles could help to relieve SI-joint related pelvic pain.
Static forces; Sacroiliac joints; Pelvis; Pelvic floor muscles; Human posture
There are currently no initial guides for the diagnosis of somatic referred pain of lumbar zygapophyseal joint (LZJ) or sacroiliac joint (SIJ). We developed a classification system of LZJ and SIJ pain, the "pain distribution pattern template (PDPT)" depending on the pain distribution patterns from a pool of 200 patients whose spinal pain source was confirmed. We prospectively applied the PDPT to determine its contribution to clinical decision-making for 419 patients whose pain was presumed to arise from the LZJs (259 patients) or SIJs (160 patients). Forty-nine percent (128/259) of LZJ and 46% (74/160) of SIJ arthopathies diagnosed by PDPT were confirmed by nerve blocks. Diagnostic reliabilities were significantly higher in Type A and C patterns in LZJ and Type C in SIJ arthropathies, 64%, 80%, and 68.4%, respectively. For both LZJ and SIJ arthropathies, favorable outcome after radiofrequency (RF) neurotomies was similar to the rate of positive responses to diagnostic blocks in Type A to Type D, whereas the outcome was unpredictable in those with undetermined type (Type E). Considering the paucity of currently available diagnostic methods for LZJ and SIJ arthropathies, PDPT is useful in clinical decision-making as well as in predicting the treatment outcome.
Low Back Pain; Zygapophyseal Joint; Sacroiliac Joint; Diagnosis; Radiofrequency Neurotomy
After lumbar or lumbosacral fusion for various spine disorders, adjacent segment disease has been reported. Most of the studies have focused on proximal segment disease. The author has reported sacroiliac joint degeneration in these patients. Based on our own experiences with an increasing number of patients with sacroiliac joint (SIJ) arthralgia after multi-level lumbar or lumbosacral fusion procedures, we evaluated a surgical procedure called distraction arthrodesis of the SIJ for patients with refractory severe pain of the SIJ.
Materials and Methods:
Nineteen (19) consecutive patients were recruited and evaluated prospectively after undergoing distraction arthrodesis of the SIJ. The inclusion criteria for the surgical procedure were degeneration of the SIJ and failed conservative treatment. Magnetic resonance imaging (MRI) scans and CT scans were performed in all cases. The clinical outcome was assessed using the Visual Analog Scale and the Oswestry Disability Index (ODI). CT scans were performed postoperatively and again at the final followup to evaluate assess fusion. The data was analyzed using the SPSS software (version 10.0; SPSS, Chicago, IL) and statistical analysis was performed. The P values were based on the Student t-test.
The mean followup was 13.2 months. All patients had an instrumented lumbar or lumbosacral fusion. The overall fusion rate of SIJ was 78.9% (15/19 joints). All patients demonstrated significant improvement in VAS and ODI scores compared to preoperative values. The mean VAS score was 8.5 before surgery and was 6 at final followup, demonstrating 30% improvement. The mean ODI scores were 64.1 before surgery and 56.97 at the final followup, demonstrating 12% improvement.
Refractory sacroiliac pain as a result of multi-level fusion surgery can be successfully treated with minimally invasive arthrodesis. It offers a safe and effective treatment for severe SIJ pain. Careful patient selection is important.
Arthrodesis; distraction; interference; recesses; sacroiliac joint
A dysfunction of a joint is defined as a reversible functional restriction of motion presenting with hypomobility according to manual medicine terminology. The aim of our study was to evaluate the frequency and significance of sacroiliac joint (SIJ) dysfunction in patients with low back pain and sciatica and imaging-proven disc herniation. We examined the SIJs of 150 patients with low back pain and sciatica; all of these patients had herniated lumbar disks, but none of them had sensory or motor losses. Forty-six patients, hereinafter referred to as group A, were diagnosed with dysfunction of the SIJ. The remaining 104 patients, hereinafter referred to as group B, had no SIJ dysfunction. Dysfunctions were resolved with mobilizing and manipulative techniques of manual medicine. Regardless of SIJ findings, all patients received intensive physiotherapy throughout a 3-week hospitalisation. At the 3 weeks follow-up, 34 patients of group A (73.9%) reported an improvement of lumbar and ischiadic pain, 5 patients were pain free. Improvement was recorded in 57 of the group B patients (54.8%); however, nobody in group B was free of symptoms. We conclude that in the presence of lumbar and ischiadic symptoms our presented data suggest consideration of SIJ dysfunction, requiring manual medicine examination and, in the presence of SIJ dysfunction, appropriate therapy, regardless of intervertebral disc pathomorphology. This could avoid wrong indications for nucleotomy.
Key words Lumbar disc herniation; Sacroiliac joint dysfunction; Manual therapy
The high frequency of static and dynamic palpation methods used during evaluation of SIJ problems in clinical practice demands an understanding of the factual quantity of movement at the SIJ. The objective of this systematic literature review was to synthesize three-dimensional (3-D) motion of the sacroiliac joint (SIJ) during various functional static postures and movements and to determine the clinical utility of movement during examination. A computer-based search was performed by means of OVID, which included Medline (February 1966 to April 2007) and CINAHL (February 1982 to April 2007) using the key words Pelvis, Kinematics, Imaging, Three-dimensional, and Stereophotogrammetric. Articles included in-vivo or in-vitro studies that investigated human SIJs with 3-D analysis. Three-dimensional analyses conducted using mathematical modeling, computerized modeling, and/or skin markers were not included because of concerns of transferability and validity. Studies that failed to report standard error of measurement (SEM) or defined tabulated values for translations or rotations using the Cartesian coordinate system were not considered for this study. Studies included for review were analyzed by the SBC biomechanical checklist to measure the quality of procedural design. Seven manuscripts were eligible for inclusion in this study. Rotation ranged between −1.1 to 2.2 degrees along the X-axis, −0.8 to 4.0 degrees along the Y-axis, and −0.5 to 8.0 degrees along the Z-axis. Translation ranged between −0.3 to 8.0 millimeters (mm) along the X-axis, −0.2 to 7.0 mm along the Y-axis, −0.3 to 6.0 mm along the Z-axis. Motion of the SIJ is limited to minute amounts of rotation and of translation suggesting that clinical methods utilizing palpation for diagnosing SIJ pathology may have limited clinical utility.
Sacroiliac Joint; Cartesian Coordinate System; Roentgen Stereophotogrammetric Analysis; Pelvic Kinematics; Systematic Review
Erosions of the sacroiliac joints (SIJ) on pelvic radiographs of patients with ankylosing spondylitis (AS) are an important feature of the modified New York classification criteria. However, radiographic SIJ erosions are often difficult to identify. Recent studies have shown that erosions can be detected also on magnetic resonance imaging (MRI) of the SIJ early in the disease course before they can be seen on radiography. The goals of this study were to assess the reproducibility of erosion and related features, namely, extended erosion (EE) and backfill (BF) of excavated erosion, in the SIJ using a standardized MRI methodology.
Four readers independently assessed T1-weighted and short tau inversion recovery sequence (STIR) images of the SIJ from 30 AS patients and 30 controls (15 patients with non-specific back pain and 15 healthy volunteers) ≤45 years old. Erosions, EE, and BF were recorded according to standardized definitions. Reproducibility was assessed by percentage concordance among six possible reader pairs, kappa statistics (erosion as binary variable) and intraclass correlation coefficient (ICC) (erosion as sum score) for all readers jointly.
SIJ erosions were detected in all AS patients and six controls by ≥2 readers. The median number of SIJ quadrants affected by erosion recorded by four readers in 30 AS patients was 8.6 in the iliac and 2.1 in the sacral joint portion (P < 0.0001). For all 60 subjects and for all four readers, the kappa value for erosion was 0.72, 0.73 for EE, and 0.63 for BF. ICC for erosion was 0.79, 0.72 for EE, and 0.55 for BF, respectively. For comparison, the kappa and ICC values for bone marrow edema were 0.61 and 0.93, respectively.
Erosions can be detected on MRI to a comparable degree of reliability as bone marrow edema despite the significant heterogeneity of their appearance on MRI.
It has been suggested that tight hamstring muscle, due to its anatomical connections, could be a compensatory mechanism for providing sacroiliac (SI) joint stability in patients with gluteal muscle weakness and SIJ dysfunction. The purpose of this study was to determine the relationship between hamstring muscle length and gluteal muscle strength in subjects with sacroiliac joint dysfunction. A total of 159 subjects with and without low back pain (LBP) between the ages of 20 and 65 years participate in the study. Subjects were categorized into three groups: LBP without SIJ involvement (n = 53); back pain with SIJ dysfunction (n = 53); and no low back pain (n = 53). Hamstring muscle length and gluteal muscle strength were measured in all subjects. The number of individuals with gluteal weakness was significantly (P = 0.02) higher in subjects with SI joint dysfunction (66%) compared to those with LBP without SI joint dysfunctions (34%). In pooled data, there was no significant difference (P = 0.31) in hamstring muscle length between subjects with SI joint dysfunction and those with back pain without SI involvement. In subjects with SI joint dysfunction, however, those with gluteal muscle weakness had significantly (P = 0.02) shorter hamstring muscle length (mean = 158±11°) compared to individuals without gluteal weakness (mean = 165±10°). There was no statistically significant difference (P>0.05) in hamstring muscle length between individuals with and without gluteal muscle weakness in other groups. In conclusion, hamstring tightness in subjects with SI joint dysfunction could be related to gluteal muscle weakness. The slight difference in hamstring muscle length found in this study, although statistically significant, was not sufficient for making any definite conclusions. Further studies are needed to establish the role of hamstring muscle in SI joint stability.
Low back pain; Sacroiliac joint; Hamstring muscle length; Gluteal muscle weakness; Pelvic dysfunction; Muscle imbalance
Clinical practice guidelines state that the tissue source of low back pain cannot be specified in the majority of patients. However, there has been no systematic review of the accuracy of diagnostic tests used to identify the source of low back pain. The aim of this systematic review was therefore to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint or sacroiliac joint (SIJ) as the source of low back pain. MEDLINE, EMBASE and CINAHL were searched up to February 2006 with citation tracking of eligible studies. Eligible studies compared index tests with an appropriate reference test (discography, facet joint or SIJ blocks or medial branch blocks) in patients with low back pain. Positive likelihood ratios (+LR) > 2 or negative likelihood ratios (-LR) < 0.5 were considered informative. Forty-one studies of moderate quality were included; 28 investigated the disc, 8 the facet joint and 7 the SIJ. Various features observed on MRI (high intensity zone, endplate changes and disc degeneration) produced informative +LR (> 2) in the majority of studies increasing the probability of the disc being the low back pain source. However, heterogeneity of the data prevented pooling. +LR ranged from 1.5 to 5.9, 1.6 to 4.0, and 0.6 to 5.9 for high intensity zone, disc degeneration and endplate changes, respectively. Centralisation was the only clinical feature found to increase the likelihood of the disc as the source of pain: +LR = 2.8 (95%CI 1.4–5.3). Absence of degeneration on MRI was the only test found to reduce the likelihood of the disc as the source of pain: −LR = 0.21 (95%CI 0.12–0.35). While single manual tests of the SIJ were uninformative, their use in combination was informative with +LR of 3.2 (95%CI 2.3–4.4) and −LR of 0.29 (95%CI 0.12–0.35). None of the tests for facet joint pain were found to be informative. The results of this review demonstrate that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain. However, the changes in probability are usually small and at best moderate. The usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear.
Electronic supplementary material
The online version of this article (doi:10.1007/s00586-007-0391-1) contains supplementary material, which is available to authorized users.
Systematic review; Low back pain; Diagnosis
Study design: Retrospective case series.
Objective: To assess fusion rates in patients with sacroiliac joint (SIJ) pain following a minimally invasive technique using fibular dowel allograft.
Methods: Thirty-seven consecutive patients (mean age: 42.5 years [range, 23–63 years]) with SIJ pain treated with 38 minimally invasive elective SIJ arthrodeses were retrospectively reviewed using chart and x-ray data. The fusion procedure consisted of minimal muscle stripping over the posterior SIJ and insertion of a cranial and caudal fibular dowel graft across the joint following placement of Steinmann pins. Fusion was deemed to be present when bone bridging trabeculae could be seen crossing the SIJ on either oblique x-rays or by computed tomographic scan. Patients were followed-up for a mean of 52 months (range, 24–62 months). Visual Analog Scale (VAS) was used to monitor clinical pain improvement.
Results: Thirty-four patients with SIJ arthrodeses (89.5%) healed and led to substantial improvement in VAS pain scores (preoperative 9.1, postoperative 3.4) (P < .001). This improvement in VAS occurred over a 6-month period and was sustained through subsequent follow-up. Nonunion occurred in four patients with SIJ (10.5%). Each SIJ nonunion was successfully treated by secondary autogenous bone grafting and compression screw fixation.
Conclusions: In patients with primary low back pain attributable to the SIJ, a minimally invasive, dual fibular dowel graft provided high rates of fusion and improved pain scores.
A model of sacroiliac joint (SIJ) function postulates that SIJ shear is prevented by friction, dynamically influenced by muscle force and ligament tension. Thus, SIJ stability can be accommodated to specific loading situations. The purpose of this study was to examine, in vivo, whether muscles contribute to force closure of the SIJ. SIJ stiffness was measured using a verified method combining color Doppler imaging with induced oscillation of the ilium relative to the sacrum in six healthy women. SIJ stiffness was measured both in a relaxed situation and during isometric voluntary contractions (electromyographically recorded). The biceps femoris, gluteus maximus, erector spinae, and contralateral latissimus dorsi were included in this study. Results were statistically analyzed. The study showed that SIJ stiffness significantly increased when the individual muscles were activated. This held especially true for activation of the erector spinae, the biceps femoris and the gluteus maximus muscles. During some tests significant co-contraction of other muscles occurred. The finding that SIJ stiffness increased even with slight muscle activity supports the notion that effectiveness of load transfer from spine to legs is improved when muscle forces actively compress the SIJ, preventing shear. When joints are manually tested, the influence of muscle activation patterns must be considered, since both inter- and intra-tester reliability of the test can be affected by muscle activity. In this respect, the relation between emotional states, muscle activity and joint stiffness deserves further exploration.
Sacroiliac joint; Stabilization; Emotions; Doppler; Electromyography
The effect of altered gait on body mechanics presents a stress on patient’s sacroiliac joints (SIJ). The gait of the patient is this case report is altered because of a transtibial amputation with prosthesis; he also has a foot drop orthotic.
A 40-year-old man had left sacroiliac pain. The pain began 3 days before visiting the clinic and has been constant since its onset. It is alleviated by resting on his side. He reported that he had been painting his mother’s house for 3 days before the pain started. Past history is significant for a spinal cord injury with resultant right leg foot drop; in addition, he has a left leg prosthesis.
INTERVENTION AND OUTCOME
Adjustments to the sacroiliac joint were performed on a Zenith-Thompson Terminal Point adjusting table, utilizing only motion palpation to assess for subluxation. The adjustments consisted of contacting the left posterior superior iliac spine (PSIS) and applying 3 successive high-velocity, low-amplitude thrusts to it. Initial visit schedules were bi-weekly and progresses to bi-monthly as needed.
Patient with prosthesis can benefit greatly from chiropractic care, to assist them in maintaining proper joint motion and gait patterns that allow them to walk more freely.
low back pain; amputation; prosthesis
A previously undescribed method for posterior fusion of the sacroiliac joint (SIJ) utilizing the Cloward instrumentation is presented, suitable for cases with chronic pain and intact ligamental structures of the SIJ. The advantages of the method in comparison with other described options include minimal disturbance of the periarticular structures, avoidance of introduction of metalwork and preservation of the iliac crest contour. This technique has been used in five cases with follow-up longer than 2 years (mean 29 months, range 25–41 months). In all cases there was resolution of their painful symtomatology.
Sacroiliac joint; Fusion; Chronic pain
This study compares the frequency and distribution of increased activity on 18 F-fluoride PET/CT with the presence of bone marrow edema on whole-body MR imaging in the spine and sacroiliac joints (SIJ) of patients with active ankylosing spondylitis (AS).
Ten patients (6 men and 4 women), between 30 and 58 years old (median 44) with active AS, were prospectively examined with both whole-body MRI and 18 F-fluoride PET/CT. Patients fulfilled modified NY criteria and had a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of at least 4. Increased radiotracer uptake in PET/CT and bone marrow edema in whole-body MRI of spine and SIJ was evaluated independently by two blinded observers for each modality. Kappa statistics were used to compare interobserver agreement as well as scores of consensus reading of the two imaging modalities.
Analysis of interobserver agreement for PET/CT yielded a kappa value of 0.68 for spinal lesions and of 0.88 for SIJ lesions. The corresponding kappa values for the MRI modality were 0.64 and 0.93, respectively. More spinal lesions were detected by MRI in comparison to PET/CT (68 vs. 38), whereas a similar number of SIJ quadrants scored positive in both modalities (19 vs. 17). Analysis of agreement of lesion detection between both imaging modalities yielded a kappa value of only 0.25 for spinal lesions and of 0.64 for SIJ lesions.
Increased 18 F-fluoride uptake in PET/CT is only modestly associated with bone marrow edema on MRI in the spine and SIJ of patients with AS, suggesting different aspects of bone involvement in AS.
18F-fluoride PET/CT; Whole-body MRI; Ankylosing spondylitis; Syndesmophytes; Inflammation
To characterise the immunohistological features of sacroiliitis in ankylosing spondylitis (AS) at different disease stages.
Biopsy samples from sacroiliac joints (SIJs) of five patients with AS, two with early, three with advanced changes and samples from age matched controls from one necropsy SIJ and two iliac bone marrow (BM) biopsies were studied. Paraffin sections were immunostained in triplicate for T cells (CD3, CD8), macrophages (CD68), and the cytokines tumour necrosis factor α (TNFα), interferon γ, interleukin (IL) 1β, IL6, IL10, and transforming growth factor β1 (TGFβ1). Stained cells were counted over one entire high power field (×400) per section in BM, cartilage, and other connective tissue (CT). Results are the mean of three sections.
CD3+ T cells were numerous in the BM of early AS, and in the CT of one patient with early and one with late AS, with variable proportions of CD8+ T cells. All patients with AS had more CD68+ macrophages than controls in BM and CT; in cartilage, one patient with early and one with late AS had increased CD68+ cells, some being osteoclasts. The patient with very early AS had large numbers of TNFα cells in the three tissular areas; for the other patient with early disease they were found only in CT and cartilage. IL6 was seen in 4/4 patients with AS in most areas. Patients with early disease had more T cells, TNFα, and IL6, and patients with advanced AS more TGFβ1.
The immunohistological findings of a limited sample suggest a role for BM in sacroiliitis, for TNFα and IL6 in early, active lesions, and for TGFβ1 at the time of secondary cartilage and bone proliferation.
ankylosing spondylitis; sacroiliitis; immunohistology; tumour necrosis factor α; transforming growth factor β
This study aimed to evaluate the validity of the sacral base pressure test in diagnosing sacroiliac joint dysfunction. It also determined the predictive powers of the test in determining which type of sacroiliac joint dysfunction was present.
This was a double-blind experimental study with 62 participants. The results from the sacral base pressure test were compared against a cluster of previously validated tests of sacroiliac joint dysfunction to determine its validity and predictive powers. The external rotation of the feet, occurring during the sacral base pressure test, was measured using a digital inclinometer.
There was no statistically significant difference in the results of the sacral base pressure test between the types of sacroiliac joint dysfunction. In terms of the results of validity, the sacral base pressure test was useful in identifying positive values of sacroiliac joint dysfunction. It was fairly helpful in correctly diagnosing patients with negative test results; however, it had only a “slight” agreement with the diagnosis for κ interpretation.
In this study, the sacral base pressure test was not a valid test for determining the presence of sacroiliac joint dysfunction or the type of dysfunction present. Further research comparing the agreement of the sacral base pressure test or other sacroiliac joint dysfunction tests with a criterion standard of diagnosis is necessary.
Infections of the sacroiliac joint are uncommon and the diagnosis is usually delayed. In a retrospective study, 17 patients who had been treated for tuberculosis sacroiliitis between 1994 and 2004 were reviewed. Two patients were excluded due to a short follow-up (less than 2 years). Low back pain and difficulty in walking were the most common presenting features. Two patients presented with a buttock abscess and spondylitis of the lumbar spine was noted in two patients. The Gaenslen’s and FABER (flexion, abduction and external rotation) tests were positive in all patients. Radiological changes included loss of cortical margins with erosion of the joints. An open biopsy and curettage was performed in all patients; histology revealed chronic infection and acid-fast bacilli were isolated in nine patients. Antituberculous (TB) medication was administered for 18 months and the follow-up ranged from 3 to 10 years (mean: 5 years). The sacroiliac joint fused spontaneously within 2 years. Although all patients had mild discomfort in the lower back following treatment they had no difficulty in walking. Sacroiliac joint infection must be included in the differential diagnosis of lower back pain and meticulous history and clinical evaluation of the joint are essential.
This case report describes a long distance runner with low-back pain and sacroiliac pain and proposes iliotibial band tightness as a possible causative factor.
A 38-year-old female amateur runner experienced an exacerbation of right-sided lower back and sacroiliac pain, which she had experienced for several months. The problem became worse as she increased the miles she ran. She had a positive Noble compression test and tightness of the iliotibial band on the right. Gaenslen's, Kemp's, and Patrick's tests were negative on the right, but created her pain of chief complaint. Trigger points were found in the gluteus maximus, gluteus medius, and tensor fascia lata muscles.
Intervention and Outcome
The patient was treated using chiropractic manipulative therapy, trigger point therapy and stretching of the iliotibial band. Her running schedule was also changed; at the beginning of treatment, she stopped running. As she progressed, she ran on flat surfaces, and with further rehabilitation, she resumed her pre-injury schedule and route. She did not demonstrate much improvement until extensive stretching was included in the treatment plan.
A patient had low back and sacroiliac pain that seemed to originate from a dysfunctional iliotibial band. This case illustrates that it is important to consider iliotibial band tightness as a possible cause of low back and sacroiliac pain and that proper management may need to include stretching of the iliotibial band along with trigger point therapy and chiropractic manipulation.
Athletic Injuries; Back Pain; Chiropractic; Iliotibial Band Friction Syndrome; Knee Injuries; Sacroiliac Joint
Objective: To determine sacroiliac joint compliance characteristics and pelvic floor movements in older women relative to gynecological surgery history and back pain complaints. Design: Single-visit laboratory measurement. Setting: University clinical research center. Participants: Twenty-five women aged 65 years or older. Outcome Measures: Sacroiliac joint compliance measured by Doppler imaging of vibrations and ultrasound measures of pelvic floor motion during the active straight leg raise test. Results: Doppler imaging of vibrations demonstrated test reliability ranging from 0.701 to 0.898 for detecting vibration on the ilium and sacrum sides of the sacroiliac joint. The presence of low-back pain or prior gynecological surgery was not significantly associated with a difference in the compliance or laxity symmetry of the sacroiliac joints. No significant difference in pelvic floor movement was found during the active straight leg raise test between subject groups. All P values were ≥.4159. Conclusions: Prior gynecological surgery and low-back pain were not significantly associated with side-to-side differences in the compliance of the sacroiliac joints or in significant changes in pelvic floor movement during a loading maneuver in a group of older women.
aging; back pain; gynecologic surgery; sacroiliac joint; pelvic floor; Doppler imaging of vibrations
This report describes the case of a patient with chronic idiopathic meralgia paresthetica associated with bilateral sacroiliac joint dysfunction who was managed with chiropractic care.
A 35-year-old white woman presented to a private chiropractic clinic with a complaint of numbness in the right anterolateral thigh region. Neurological assessment revealed a diminution of sensibility and discrimination on the right lateral femoral cutaneous nerve territory. Pain was rated as 8.5 on a numeric pain scale of 0 to 10. Musculoskeletal examination of the pelvic region disclosed bilateral sacroiliac joint dysfunction.
Intervention and Outcomes
Chiropractic management included pelvic mobilizations, myofascial therapy, transverse friction massage, and stretching exercises. After 3 visits (2 weeks later), result of neurological evaluation was normal, with no residual numbness over the lateral thigh.
In the present case, chiropractic management with standard and applied kinesiology techniques resulted in recovery of meralgia paresthetica symptoms for this patient.
Meralgia paresthetica; Chiropractic; Sacroiliac joint; Musculoskeletal manipulations
Tij and Delta Hij for stacking of pair i upon j in DNA have been obtained over the range 0.034-0.114 M Na+from high-resolution melting curves of well-behaved synthetic tandemly repeating inserts in recombinant pN/MCS plasmids. Results are consistent with neighbor-pair thermodynamic additivity, where the stability constant, sij , for different domains of length N depend quantitatively on the product of stability constants for each individual pair in domains, sijN . Unit transition enthalpies with average errors less than +/-5%, were determined by analysis of two-state equilibria associated with the melting of internal domains and verified from variations of Tij with [Na+]. Enthalpies increase with Tij , in close agreement with the empirical function: Delta Hij = 52.78@ Tij - 9489, and in parallel with a smaller increase in Delta Sij . Delta Hij and Delta Sij are in good agreement with the results of an extensive compilation of published Delta Hcal and Delta Scal for synthetic and natural DNAs. Neighbor-pair additivity was also observed for (dA@dT)-tracts at melting temperatures; no evidence could be detected of the familiar and unusual structural features that characterize tracts at lower temperatures. The energetic effects of loops were determined from the melting behavior of repeating inserts installed between (G+C)-rich barrier domains in the pN/MCS plasmids. A unique set of values for the cooperativity, loop exponent and stiffness parameters were found applicable to internal domains of all sizes and sequences. Statistical mechanical curves calculated with values of Tij([Na+]) , Delta Hij and these loop parameters are in good agreement with observation.
To investigate common non-traumatic musculoskeletal complaints of the low back in elite inline-speedskaters of the German national team.
Summary of background data
Traumatic injuries associated with falls or collisions are well documented in speedskaters but so far no studies have investigated non-traumatic low back pain. Previously, the sacroiliac joint was suspected as a frequent origin of complaint, we aimed to investigate this assumption.
Two chiropractors examined elite inline-speedskaters of the German national team during three sports events between summer 2010 and 2011. A test cluster of five provocative tests for the sacroiliac joint was selected based on reliability and validity.
A total of 37 examinations were conducted on 34 athletes with low back pain during the three sport events. The reported pain intensities ranged from mild to moderate pain (VAS 23.4 ± 13.4 to 35.1 ± 19.2). About 90% of cases showed involvement of the SI joint of which again 90% presented with left sided symptoms.
Non-traumatic complaints of the low back originating from the left sacroiliac joint frequently occur in competitive inline speedskaters.
Speedskating; Non-traumatic; Sacro-iliac joint; Sport-specific; Pain
The tissue origin of low back pain (LBP) or referred lower extremity symptoms (LES) may be identified in about 70% of cases using advanced imaging, discography and facet or sacroiliac joint blocks. These techniques are invasive and availability varies. A clinical examination is non-invasive and widely available but its validity is questioned. Diagnostic studies usually examine single tests in relation to single reference standards, yet in clinical practice, clinicians use multiple tests and select from a range of possible diagnoses. There is a need for studies that evaluate the diagnostic performance of clinical diagnoses against available reference standards.
We compared blinded clinical diagnoses with diagnoses based on available reference standards for known causes of LBP or LES such as discography, facet, sacroiliac or hip joint blocks, epidurals injections, advanced imaging studies or any combination of these tests. A prospective, blinded validity design was employed. Physiotherapists examined consecutive patients with chronic lumbopelvic pain and/or referred LES scheduled to receive the reference standard examinations. When diagnoses were in complete agreement regardless of complexity, "exact" agreement was recorded. When the clinical diagnosis was included within the reference standard diagnoses, "clinical agreement" was recorded. The proportional chance criterion (PCC) statistic was used to estimate agreement on multiple diagnostic possibilities because it accounts for the prevalence of individual categories in the sample. The kappa statistic was used to estimate agreement on six pathoanatomic diagnoses.
In a sample of chronic LBP patients (n = 216) with high levels of disability and distress, 67% received a patho-anatomic diagnosis based on available reference standards, and 10% had more than one tissue origin of pain identified. For 27 diagnostic categories and combinations, chance clinical agreement (PCC) was estimated at 13%. "Exact" agreement between clinical and reference standard diagnoses was 32% and "clinical agreement" 51%. For six pathoanatomic categories (disc, facet joint, sacroiliac joint, hip joint, nerve root and spinal stenosis), PCC was 33% with actual agreement 56%. There was no overlap of 95% confidence intervals on any comparison. Diagnostic agreement on the six most common patho-anatomic categories produced a kappa of 0.31.
Clinical diagnoses agree with reference standards diagnoses more often than chance. Using available reference standards, most patients can have a tissue source of pain identified.
Traditional screw or plate fixation options can be used to fix the majority of sacral fractures. However, these techniques are unreliable with dysmorphic upper sacral segments, U-fractures, osseous compression of neural elements, and previously failed fixation. Lumbopelvic fixation can potentially address these injuries but is a technically demanding procedure requiring spinal and pelvic fixation and it is unclear whether it reliably corrects the deformity and restores function.
We therefore assessed reduction quality and loss of fixation, pain related to prominent hardware, subjective dysfunction measured by the Short Musculoskeletal Function Assessment (SMFA), and complications.
We retrospectively reviewed 15 patients with unstable sacral fractures treated with lumbopelvic fixation between 2002 and 2010. Patients had radiographic monitoring regarding reduction quality and loss of fixation and clinical followup using the SMFA. The minimum followup was 12 months (mean, 23 months; range, 12–41 months).
Posterior reduction quality was 11 of 15 with less than 5 mm persistent displacement and four of 15 with 5 to 10 mm displacement. Loss of fixation was observed in one patient as a result of a technical error. Prominent hardware resulted in greater pain. Despite daily activity and bother subscores improving over time, we found long-term dysfunction in the SMFA. Eleven of the 15 patients were able to return to previous work or activities.
Complex posterior pelvic ring injuries of the sacrum not amenable to traditional fixation options can be salvaged with adherence to the technical details of lumbopelvic fixation. Hardware prominence and pain are markedly reduced with screw head recession. Long-term impairment is noted in patients with complex pelvic ring injuries requiring lumbopelvic fixation compared with normative data.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.