Rehabilitation for SI Joint Pain and/or Dysfunction

The sacroiliac (SI) joint is the joint between the sacrum and the ilium bones. The sacrum supports the spine and is itself supported by the ilium on either side. The SI joint is meant to remain relatively stable as opposed to a highly mobile joint like the shoulder which moves a great deal in order to reposition the arm. The SI joint does move a small amount in order to transfer forces between the body and the legs, acting as a type of shock absorber.

We have a right and a left SI joint. The surfaces of the joints have irregular elevations and depressions that results in interlocking of the joint surfaces. There are strong non-elastic connective fibers called ligaments that stabilize the front and back of the joint. 1 In addition, there are multiple strong muscle groups that cross over the joint providing additional stability.

1 Figure 1 - Sacroiliac (SI) Joint

1 Figure 1 - Sacroiliac (SI) Joint

1 Figure 1 - Sacroiliac (SI) Joint

×

When a patient is diagnosed with SI joint dysfunction, non-surgical treatment is typically recommended as the first-line of treatment and is continued if the patient is continuing to get adequate relief from their symptoms. Non-surgical treatment may include medication, physical therapy including a trial of SI-belting, injections, and radiofrequency ablation. This article will address the physical therapy component of non-surgical treatment, referred to as rehabilitation. Physical therapy may or may not be combined with the other treatments described above.

Figure 2 - Sacroiliac Ligaments

Figure 2 - Sacroiliac Ligaments

Figure 2 - Sacroiliac Ligaments

×

Pain and altered function of the SI joint that is not related to an inflammatory condition, such as Psoriatic arthritis, or other pathologic process such as tumor or infection, is often referred to as sacroiliac joint dysfunction (SIJD). There is not a universally accepted definition of SIJD, however, SIJD generally refers to pain in the SI joint region that is caused by or results in altered function of the SI joint. There may be either too much or too little joint motion, the ligaments may be too tight or too stiff, the muscles supporting the SI joint could be damaged or not working correctly, there could be too much or too little joint compression, or there could be other factors such as a leg length inequality that lead to abnormal loading of the joint. A patient may have one or more than one of these factors contributing to their pain. SIJD may result in degeneration of the SI joint. This may also lead to pain in the muscles and connective tissues surrounding the joint or that extend from the SI joint to adjacent joints.

SI Joint Dysfunction

SI Joint Dysfunction

SI Joint provocative tests photo

Figure 5 - SI Joint Provocative Tests

Non-surgical treatment of the SI joint isn’t limited to treatment of the joint itself, but also includes treatment of contributing factors that can lead to dysfunction and pain both at the SI joint and in the adjacent muscles, ligaments and joints. As patients with SIJD can be quite different (a 35-year old post- partum female as opposed to a 65-year old male with multiple prior lumbar fusions) there is not a single treatment plan that is right for every patient. The best way to treat SI joint pain with rehabilitation is to identify and then treat the underlying soft tissue impairments. This should be accompanied by symptom relief so that treatment is well tolerated. This treatment plan assumes that the healthcare practitioner has already ruled out pain associated with pathological processes including inflammatory arthritis, infections, tumors and acute fractures with blood tests and diagnostic tests such as x-rays, CAT scans, MRIs, etc.

Rehabilitation for the SI Joint

Goals

Physical therapy, as a profession, is not uniform and there are different schools of thought regarding treatment of SI joint disorders. However, the goals of rehabilitation for SI joint pain typically include:

  1. Return the SI joint it to its normal position 4 and maintain this position. Optimal SI joint function occurs with the SI Joint in neutral (mid-range) position. 5-13
  2. Restore optimal alignment of the lumbar spine, sacroiliac joint and hip joints
  3. Optimize functional stability of the lumbopelvic region by restoring normal function of the supporting muscles

Evaluation

Prior to treatment the physical therapist performs a thorough evaluation and identifies problems in the following areas that may affect the three goals above:

Treatment Plan

After the evaluation, the physical therapist will create a treatment plan to address the deficits described above. When creating this treatment plan, the physical therapist takes into consideration the patient’s functional goals. Functional goals are the activities that the patient needs to perform so that they can perform their self-care, occupational and recreational activities in a manner such that they can live with their SI joint dysfunction.

Treatment

There is very little published clinical evidence for any one specific treatment technique for SI joint dysfunction. Physical therapy is a profession, rather than a specific treatment. As such, physical therapists are educated to identify and treat impairments identified during the evaluation based on published research and what is termed “best practice”. The underlying impairments described above are identified and then treated. The goal is to achieve the three functional goals and ultimately assist the patient in achieving pain-free function with their daily activities.

One of the most important aspects of an effective treatment program is patient education. The patient should be educated as to the potential cause(s) of the SI joint dysfunction They should also be educated on how they need to be an active participant in their care. This includes following recommendations to change the way the patient positions themselves, moves during daily self-care and recreational activities, including methods to independently reduce their pain. This may include application of heat or ice, resting when advised, and performing specific exercises.

The patient will frequently be given a home exercise program. This program will be specifically designed to address the impairments of each individual patient. Effective and frequent communication between the patient and physical therapist is important to assure the exercises are within the patient’s pain tolerance and abilities.

Treatment Components

These are the parts of treatment that may help with the alleviation of SI joint dysfunction.

Modification of Activities of Daily Living (ADLs)

Patient education regarding maintaining optimal alignment with positioning, posture and body mechanics

The physical therapist will educate the patient regarding the best way to sit, stand, move, sleep, and perform daily activities to prevent body positions that may decrease the ability of the core muscles to function resulting in additional strain on the SI joint. The suggestions may include avoidance of:

Instruction in Stabilization (Core Strengthening) Exercises