Sacroiliac dysfunction - the other low back pain
There are a significant number of reasons for the onset of low back pain. Lumbar facet compressions caused by poor posture and perhaps aggravated by arthritic degeneration. Fractures or tears from athletic or other traumatic accidents. Nerve compression caused by disc bulges, or foramen compressions, or arthritis, or central stenosis, or overactive extensor muscles, or poor posture, or.... well, you get the idea. These and many more contribute to the complicated and multifaceted issue that is low back pain.
Perhaps a more poorly appreciated cause of low back pain however is sacroiliac joint (SIJ) dysfunction. It’s the original pain in the butt! The SIJ is the junction between the sacrum (tailbone) at the bottom of the spine and the rest of the pelvis. It’s a sensitive little guy that you can feel by finding the bony dimple at the upper part of your butt, a couple of inches toward the outside from the midline on either side and extending down in inward on a line toward the bottom of the tailbone. See the picture below.
Fig 1 - the sacroiliac joint, imaged with help from Essential Anatomy 3, my favorite app. The joint is circled in yellow. On the right, stabilising muscles are highlighted (lattisimus dorsi [A] and Glute max [B]) as are the fibers of each, crossing and stabilising the joint.
Pain at this joint is estimated to be clinically relevant in 15-25% of all cases of low back pain. Deciding if you are one of those for whom this is an issue can be determined fairly accurately at the office of your physiotherapist using a cluster of clinical tests designed to provoke pain from the SIJ (but not from other sources). I should note that ironically the gold standard test for SIJ dysfunction is to inject analgesic (pain relieving) medication into or around the joint and wait to see if it helps, somewhat invasive but it works!
Like the varied causes of low back pain, the solutions for sacroiliac dysfunction are diverse, there is no one size fits all fix. Lots of solutions have been proposed in the research. The abovementioned injection therapies using corticosteroid and/or local anesthetic drugs is one. Another type of injection therapy, proliferative (or “prolo”) therapy involves the use of medications to induce an inflammatory (remodelling) response to strengthen the sensitive ligaments across the joint and therefore stabilise it.
Another treatment, radiofrequency denervation uses heat to destroy the sensory nerves that supply the SIJ. Researchers do report good success treating SIJ pain using this method although it is not possible to access all of the relevant nerves so this treatment is both quite invasive and by no means perfect.
These treatments are all on the more more invasive side and if we can avoid (or at least compliment) them through treatment using more conservative means we absolutely should!
For our purposes as a physiotherapy blog, we are interested what we can do conservatively at home to manage our pain, and exercise is certainly an important component of that. Strength training of muscles that cross and stabilise the SIJ has been researched as a successful treatment method. Specifically the glutes (and even more specifically the gluteus maximus) as well as the latissimus dorsi (the “lats”) muscle have been suggested to act as stabilisers of this joint.
Check out the the video above for a detailed demonstration of an exercise protocol designed to strengthen these muscles. If for quick reference though, try these simple exercises.
For the first two weeks, start with:
Bilateral bridge: Lay supine (on your back) with your knees bent and your feet flat on the floor. Push your pelvis up to create a flat line from shoulders to knees. Slowly lower and repeat 10 times.
unilateral bridge: with only one foot planted on the floor once again push your pelvis up to create a flat line from shoulders to knees. Slowly lower and repeat 10 times.
Quadruped hip extension: From a hands and knees position (this is known as “quadruped”) and with your knee bent to 90 degrees as shown. Lift the leg to create a straight line from your trunk to your knee. Slowly lower and repeat 10 times.
Seated pulldown: Sitting in a chair with a resistance band anchored overhead (I suggest using a simple doorjam anchor available at any fitness store or from amazon, something like this) execute a one handed pulldown, at the bottom of the movement your hand should be at the chest wall. Slowly release and repeat 10 times.
Then after 2 weeks add in:
Quadruped abduction and external rotation (“fire hydrant” exercise): from a quadruped position, raise your leg out to the side, maintain a bend at the knee. Slowly lower and repeat 10 times.
One legged deadlift: stand on one leg. Bending at the hip with the other leg extended behind you, lower your trunk to touch a weight situated at a low position. Your stance leg stays relatively straight. Slowly return to the start position, not touching the free leg to the floor (stay on one leg). Repeat 10 times.
Try this exercise protocol at least two times/week although I’d suggest 3 times for gold stars. It takes some time to generate pain relieving change (expect 6 weeks) but you should be able to say that you are moving in the right direction within 2-3 weeks.
If you have questions about this or anything else required for moving beautifully, please don’t hesitate to reach out!
Further reading (if you really want to impress your friends)
Added, M. A. N., de Freitas, D. G., Kasawara, K. T., Martin, R. L., & Fukuda, T. Y. (2018). STRENGTHENING THE GLUTEUS MAXIMUS IN SUBJECTS WITH SACROILIAC DYSFUNCTION. International journal of sports physical therapy, 13(1), 114.
Cohen, S. P., Chen, Y., & Neufeld, N. J. (2013). Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert review of neurotherapeutics, 13(1), 99-116.
Cusi, M., Saunders, J., Hungerford, B., Wisbey-Roth, T., Lucas, P., & Wilson, S. (2008). The use of prolotherapy in the sacro-iliac joint. British Journal of sports medicine.
Mooney, V., Pozos, R., Vleeming, A., Gulick, J., & Swenski, D. (2001). Exercise treatment for sacroiliac pain. Orthopedics, 24(1), 29-32.
Peebles, R., & Jonas, C. E. (2017). Sacroiliac joint dysfunction in the athlete: diagnosis and management. Current sports medicine reports, 16(5), 336-342.
van der Wurff, P., Buijs, E. J., & Groen, G. J. (2006). A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Archives of physical medicine and rehabilitation, 87(1), 10-14.