Vadim Kalganov BOst
“Osteopaths commonly claim to restore both positional and movement symmetry to the ilio-sacral joint. Discuss the rationale regarding the restoration of function including a review of the evidence that supports such claims.”
The dysfunction of ilio-sacral joint could be one of the reasons causing lower back pain. Positional and movement asymmetry of ilio-sacral joint might contribute to this potentially disabling condition. The purpose of this essay is to discuss the claim that osteopaths can restore the symmetry of ISJ (ilio-sacral joint) and whether it is done by affecting the joint movement or via pain relief by a centrally mediated mechanism.
According to Tortora (2009), the ISJ is a synovial joint with slight gliding movement. The joint contains numerous ridges and depression, indicating its function for stability more than for motion. Stability also provided by large sized posterior and anterior ligaments and enhanced by muscles and fascia. Piriformis, biceps femoris, gluteus maximus and minimus, erector spinae, latissimus dorsi thoracolumbar fascia and iliacus muscles provide support for the joint. ISJ has limited motion, most of the movement takes place around a transverse axis, situated at the level of the second sacral vertebra, the most movement occurs when rising from sitting to standing position, however Harrison (1997) suggests that hyperextension produces the greatest degree of motion. The motion of the joint is complex, involving simultaneous rotations of 3 degrees or less and translation of 2 mm or less in three dimensions.
Occupational repetitive lifting can be causing factor of ISJ motion asymmetry. DonTigny (1990) wrote “when trunk is flexes, weight shifts anteriorly, causes an anterior rotation force, the pelvis rotates anteriorly and downwards around acetabula. After innominate rotates anteriorly on the sacrum, the articular surfaces are altered in such a way as to allow the innominate to slip vertically upwards on the sacrum and lock, effectively preventing correction by simple posterior rotation. While bending with weight lifting, rotated anteriorly innominates are fixed on the sacrum, finally when the subject straightens, the addition of the weight causes the sacrum to settle vertically downward and more effectively locks the SIJ in the position of asymmetry”. DonTigny (1990) also suggested that standing in lordotic posture also increases the anterior rotation of ilium on sacrum. Posterior dysfunction, according to the same author probably does not exist, because ISJ function most efficiently to absorb compression when the innominate moves posteriorly where it is well protected from injury by the dense posterior ligament. According to DonTigny’s opinion “no mechanism has been described that might cause innominates to wedge and lock, when moving posteriorly on the sacrum”.
Shaffrey (2013) wrote that degeneration and inflammatory processes within ISJ may include arthritis, osteophythosis, arthrosis and ankylosis, prior lumbosacral fusion, hip arthritis, infections, and neoplasia, those conditions may affect the articular surfaces of the joint and surrounding or supportive structures, contributing to restriction of motion. The other predisposing conditions that might cause asymmetrical motion or locked position of ISJ could include congenital factors, such as scoliosis or legs length inequity, when innominate rotated posteriorly and upwards on the sacrum on the side of the longer limb, and anteriorly and downwards on the side of shorter leg to a corrected position.
The ISJ asymmetry might also be predisposed by lack of support of once strong and tight ligaments. Weakened, injured or sprained ligaments caused by torsion, high impact injury or hard fall, result in the hypermobility of ISJ. “The joint with stretched ligaments will move beyond its normal range. This is thought to result in ilium and sacrum “locking” in asymmetrical fashion” wrote Shaffrey (2013). Hormone imbalance and pregnancy can cause ligamentous laxity and as result hypermobility of the joint in women before menstruation or later stage of pregnancy. Women are more at risk for ISJ problems, because their broader pelvises, greater femoral neck anteversion and shorter limb lengths lead to predisposing biomechanics. The larger the distance between the ISJs and the midline, the less stable the joint, as rotational torque increases as a function of the lever arm. Features such as coarse texture, ridges and depressions, enhance friction and consequently stability of the ISJ. In general, less pronounced ridges and grooves appeared in younger female than relatively older males and females. Stoev (2012), reports that of patients who presented with SIJ misalignments, 77% were female.
“As the sacrum is wider anteriorly than posteriorly, any movement of the innominates anteriorly on the sacrum tends to spread the innominates and may cause them to wedge or bind” says DonTigny (1985). In addition “muscle forces actively compress the SIJ, preventing shear. SIJ stiffness increases even with slight muscle activity” states Harrison (1997). Excessive movement of ISJ can create some “protective action” by adjacent tissues. Muscles will contract in spasm in an attempt to pull the joint back to correct location or stabilise it and to protect the joint from further damage. This might be the cause of the movement asymmetry, when ilium became fixed to the sacrum in neutral position.
Trauma (e.g. falling on the buttock) and injury could play significant role in ISJ dysfunction “more than half of patients diagnosed with SIJ pain had some inciting traumatic injury” says Sherman (2014). “If the subject with anteriorly rotated innominate step down hard or fall on his buttocks, the sudden deceleration is combined with the internal moment acting on the sacrum, and sacrum is forced vertically downward on the ilium, locking SIJ in position of dysfunction” stated DonTigny (1985).
Muscle imbalance might also contribute to asymmetry of ISJ, according to Fritz (1995, p 262) “muscle spasm and contraction may pull the joint out of alignment”. His statement was agreed by Chaitow (2006), he says “if the muscles on one side of a joint are tight and the opposing muscles relax, the joint will be pulled out of alignment towards the tight muscle(s)”. Sherman (2014) added “the certain biomechanical or muscle length imbalances may ultimately predispose a person to SIJ dysfunction. Likely this is a result of altered gait pattern and repetitive stress to SIJ and related structures”. Also Sheriman noted that patients with ISJ dysfunction can develop tightness and dysfunction in hamstring, quadriceps, iliotibial tract and hip flexors including psoas muscle. Sherman’s founding was supported by Arab (2011), who suggested that hamstring muscles may posteriorise the ilium while contracting, when gluteal muscles ability to stabilise the joint is compromised. However, Sherman (2014) notes that factors that specifically increase the likelihood ISJ dysfunction have not been identified.
In general, dysfunction defined as impaired function. The function of ISJ is to disperse load and to be mobile. Pain can be indication of dysfunction in asymmetrical joint, DonTigny (1990) says “impaired function of SIJ can cause pain” so until mobility is restored, it might be suggested, that the pain would be present. Therefore ISJ function restoration may include restoration of mobility of the joint and pain relief. Osteopaths may influence the sacro-iliac positional and movement symmetry applying MET and joint manipulation. If the movement or positional asymmetry of ISJ is caused by surrounding muscle spasms, locking the joint, Fritz (1995, p 265) found “MET may lessen the protective spasm and movement restriction to resolve mobility”. His opinion was confirmed by Stoev (2012), who conducted the study on young female athletes with ilio-sacral positional asymmetry and used MET Isometric hip extension and flexion to realign the IS joint. Stoev found that 80% of his patient had dramatic improvement of symptoms, after sacroiliac symmetry was resolved.
The effectiveness of SIJ manipulation in the form of HVLA (high-velocity low-amplitude) was presented in the study Kamali (2012), who found it very effective in restoration of ilio-sacral function and significant pain reduction. This was also confirmed by study of Shearar (2005) and Osterbauer (1993), who both found SIJ manipulation very successful for restoring asymmetry of ISJ and pain reduction derived from dysfunction of the joint. However, Laslett (2008) disagreed on efficiency of manipulating treatment of SIJ; he wrote “the treatments with the most potential for reductions in pain of SIJs are exercises aimed at improvement in lumbopelvic stability and intra-articular steroid injections”. Laslett based his point of view on the opinion, that the tests used by osteopaths for diagnosis are not sufficiently reliable and there is a possibility to miss degenerative condition. Manipulation, in this case may cause more pain and other symptoms aggravation, rather than benefit.
MET and joint manipulation applied by the therapist in above mentioned studies for function restoration of ilio-sacral joint, successfully restored the asymmetry of the joint, but more importantly it reduced the pain which was the primer complaint that patient addressed. “Pain is the key element in diagnosis of SIJ dysfunction” states Laslett (2008), Poley (2008) continued “excessive or restricted motion at the SIJ can alter the mechanics of the spine and pelvis causing pain”. “Changes in the joint position or mechanics can be a pain generator resulting from joint capsule or ligamentous tension and resultant inflammation” explains Stoev (2012), adding that muscle spasm is the other possible contributor to pain. There is a possibility that pain relief by manipulation was due to some centrally mediated mechanism, not by restoration of mobility. The study conducted by Orakifar (2012) showed that SIJ manipulation do not affect pain threshold and only reduce muscle spasm for 20 sec, just enough to break “pain-spasm-pain” cycle. The result of this study suggests that until mobility is restored, the pain will remain originating from ligament, capsule and shortly after reoccurred spasm. This statement is in conjunction with the fact that in studies performed by Osterbauer (1993), Shearar (2005) and Stoev (2012), the most patients with restored mobility remained symptoms free for at least one month after the treatment. Therefore, the claim that SIJ manipulations could elevate pain (derived from impaired mobility) by restoring mobility is supported by Orakifar’s study.
In conclusion, the claim by the osteopaths to restore both positional and movement symmetry to the ilio-sacral joint is found to be grounded and supported by studies. The MET and SIJ manipulation employed by therapists are not invasive forms of the treatment and found to be effective for the patients with ISJ dysfunction.
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