The treatment of the sacroiliac joint component to low back pain: a case report.

The sacroiliac joints are often considered a source of low back pain.[1-7] Debate has continued over the existence of sacroiliac joint dysfunction. Some view the sacroiliac joint as an insignificant contribution to low back pain[8-10] whereas others believe the sacroiliac joint plays a major role in low back pain.[1-7] believe that the sacroiliac joint contributes to low back pain.[11]

Studies[12,13] have shown a relationship between the sacroiliac joint and limited hip mobility. Dunn et al[12] reported that in multiple patients pyogenic infection of the sacroiliac joint resulted in limited hip mobility, limited straight leg raising, and pain when the pelvis was compressed (ie, by application of pressure in a posterior and lateral direction over the supine patient's anterior superior iliac spines [ASISs]). LaBan et al[13] found asymmetry in hip mobility with a reduction in abduction and lateral (external) rotation in patients with sacroiliac joint dysfunction. Studies[14-16] have shown a relationship between low back pain and asymmetrical hip rotation. Fairbank et al[14] found limited hip rotation in students with back pain more often than in students without back pain. Mellin[15] found a significant correlation between recurrent low back pain and limited hip medial (internal) rotation. Ellison et al[16] reported the relationship between asymmetrical hip rotation and low back pain in patients with diagnoses of lumbar strain, disk herniation, sacroiliac joint dysfunction, and avulsion fracture. Ellison et al reported that patients with low back pain usually had more lateral hip rotation than medial rotation and that they had a greater frequency of excessive hip rotation than did those without low back pain. The purpose of this case report is to describe the treatment of a patient who appeared to have a sacroiliac joint component to low back pain and who also had unilateral asymmetrical hip rotation (ie, more lateral than medial).

Interview Data

A 32-year-old physically active male accountant, 172.7 cm (68 in) in height and 72.6 kg (160 lb) in weight, was referred to physical therapy with a complaint of unilateral, right-sided low back pain. He did not report buttock or leg pain. The patient completed a pain drawing of his perceived pain on his initial visit (day 1) (Fig. 1). The patient reported waking up with right-sided low back pain and stiffness, which had persisted for the last 4 days. He could not remember any trauma or acute injury to his low back. He reported that he developed similar right-sided low back pain and stiffness, usually lasting 2 days, every month for the past year. The patient reported, however, that this episode of low back pain and stiffness was worse than his previous episodes, The patient also reported that he developed right-sided low back pain after walking or running distances greater than 0.4 km (0.25 mile). The patient reported that, while running, he developed stiffness in the low back (Fig. 1) during the first 0.4 km, but that his stiffness subsided and his low back felt better after completing his daily 6.4-km (4-mile) run. Sitting was not painful, but he complained of an occasional pain (Fig. 1) when he moved from a sitting to a standing position. The patient complained of almost daily morning stiffness (Fig. 1) that would last approximately a half hour to an hour after getting out of bed.

The patient reported that his preferred sleeping posture was lying prone with the right knee flexed and the hip laterally rotated (Fig. 2). He reported experiencing stiffness, but no pain, in the right side of the low back when bending over to wash his face or brush his teeth (Fig. 1). Coughing or sneezing did not increase his low back pain. He reported that his work did not result in any increase in pain except for an occasional pain when moving from a sitting to a standing position. Throughout my interview of the patient, I observed that he repeatedly crossed his right leg over his left leg Fig. 3).

Physical Examination Data

On the first day the patient was seen in therapy, he perceived his low back pain as moderate. This assessment was based on the patient's Oswestry low back pain disability questionnaire score of 34. The Oswestry questionnaire measures perceived pain or disability with a score ranging from 0 to 100, with 0 the least possible perceived pain and 100 the worst possible perceived pain.[17]

Visual inspection of the standing patient showed no apparent deformity of the lumbar spine in the frontal or sagittal plane. Active spinal motion was visually assessed, but I did not measure the motion with a goniometer. Active movements were assessed to obtain a gross assessment of the patient's active range of motion (AROM) of the trunk and to determine which specific movement produced pain.[6] The patient reported that his trunk AROM in forward bending was painless, and he could touch his toes with both knees completely extended (0 [degrees] of extension). He did, however, report stiffness (Fig. 1), but no pain, in the low back upon returning from forward bending. The forward-bending motion appeared smooth without evidence of muscle guarding. Backward bending was painless, and the patient appeared to have full AROM. Left side-bending was also painless. The patient could reach his lateral knee joint line with his fingertips. On right side-bending, he could also reach his lateral knee joint line with his fingertips but he complained of low back pain and stiffness at the end of movement. The tendency to side-bend toward the side of the low back pain is common in patients who are believed to have a sacroiliac joint component to low back pain.[1]

Palpation of the pelvic landmarks while the patient stood with the knees fully extended and the feet a shoulder width apart showed a high right ASIS when compared with the left ASIS. Palpation of the posterior superior iliac spine (PSIS) indicated that it was lower on the right than on the left. A high right ASIS and a low right PSIS are said to indicate a right posterior rotation of the innominate bone (ie, sacroiliac joint dysfunction).[1] When palpating the PSIS on forward trunk bending, the right PSIS appeared to move more superior than the left PSIS. This finding is indicative of a positive standing flexion test.[1,11] A positive standing flexion test purportedly indicates limited movement of the ilia on the sacrum, displaying limited sacroiliac joint motion on that side.[1] The tests that suggest sacroiliac joint dysfunction, however, are known to yield measurements of questionable reliability.[18]

Palpation of the bony landmarks while the patient sat on a level surface showed that the right PSIS appeared lower when compared with the left PSIS.[19] The presence of a lower right PSIS suggests that the right innominate bone may be rotated posteriorly on the sacrum, whereas the left innominate bone is supposedly anteriorly rotated.[11,19]

When palpating the region medial to the right PSIS, I noted tenderness and was able to reproduce the patient's pain. Tenderness medial to the PSIS is said to suggest sacroiliac joint pathology.[20] Manual muscle tests of the hip flexors, the quadriceps femoris muscles, the ankle joint dorsiflexors, the plantar flexors, and the extensor hallucis longus muscles showed Normal muscle grades.[21] Patellar tendon and ankle reflexes were bilaterally symmetrical.

Left straight leg raising, measured with a fluid-filled goniometer,(*) was painless for 90 degrees. During right straight leg raising, the patient complained of right-sided low back pain at 75 degrees of hip flexion. Pain beyond 35 degrees is said to indicate mechanical dysfunction at a lumbar joint or a pelvic joint.1 The patient's leg lengths were examined, with the patient in the supine position, by comparing the level of the inferior aspects of both medial malleoli. The right leg appeared shorter when compared with the left leg. The reliability of this measurement technique has not been demonstrated. While holding my thumbs just distal to both medial malleoli, the patient was asked to sit up. The apparently short right leg appeared to lengthen, demonstrating a positive long-sitting test. This supine long-sitting test is supposed to suggest that the right innominate bone is rotated posteriorly, whereas the left innominate bone is rotated anteriorly on the sacrum.[1,11] The two-joint hip flexor test, used to assess the length of the hip flexor muscles,[21] did not show a difference in left or right hip extension. The FABER test reproduced right-sided low back pain (Fig. 1) only on testing the right side. The FABER test was performed by flexing the patient's hip to 90 degrees, laterally rotating and abducting the hip. A simultaneous posterior pressure was applied slowly to the medial aspect of the involved knee and the contralateral ASIS.[6] Compression of the sacroiliac joints, by applying pressure in a posterior and lateral direction over the supine patient's ASISs, created identical right-sided low back pain. Distraction of the sacroiliac joints by applying a medially directed pressure over the ASIS produced no pain. Potter and Rothstein[22] obtained reliable measurements for both sacroiliac joint compression and distraction, but all other tests of sacroiliac joint dysfunction yielded unreliable results.

Examination of leg lengths by visually comparing the left and right soles of the heels' with the patient in the prone position showed an apparently short right leg. On flexing the knees to 90 degrees, however, the apparently short right leg became longer. This positive prone knee flexion test suggested sacroiliac joint dysfunction.[1] In view of the questionable reliability of this assessment, however, the results are difficult to analyze. The prone knee flexion test suggested the presence of left anterior rotation of the innominate bone with posterior rotation of the right innominate bone.[1,11] When I applied posterior to anterior pressure over the spinous processes of all lumbar vertebrae and pushed to the fullest extent of movement, the patient reported no pain.

There was 25 degrees of medial passive range of motion (PROM) and 65 degrees of lateral PROM. The PROM of the left hip was 50 degrees medially and 45 degrees laterally. This method of measuring hip PROM has been shown to yield reliable measurements.16 Manual muscle tests showed Normal muscle grade of the right hip medial rotator muscles. The hip medial rotator muscles were tested as described by Kendall and McCreary.[21] Manual muscle tests of both hamstring muscles, administered as described by Kendall and McCreary, showed Normal grade and were pain-free. Manual muscle test grades in the Normal range, as noted in my examination, are not known to be reliable.

Assessment

My examination findings suggested to me that the patient had a sacroiliac joint dysfunction (Appendix).[11] The presence of pain around the PSIS (Fig. 1), tenderness to palpation medial to the PSIS, and the positive sacroiliac joint compression test all suggested sacroiliac joint dysfunction.[18] Potter and Rothstein[22] found that individual tests for sacroiliac joint dysfunction yielded unreliable measurements, although it is unlikely that a clinician would base an assessment of a patient on one individual finding. The use of a combination of tests and the finding of four positive tests (ie, uneven PSIS heights when sitting, a positive standing flexion test, a positive supine long-sitting test, and a positive prone knee flexion test), however, suggest the presence of sacroiliac joint dysfunction.[11] The reliability of measurements obtained using a combination of tests for sacroiliac joint dysfunction has been shown to be good, although the individual tests yielded generally unreliable measurements.[11]

My initial goal was to attempt to reduce the patient's low back pain and eliminate the apparent innominate bone rotation. Elimination of any innominate bone rotation is believed to be necessary if an examination of true leg length is to be performed. Differences in leg length have been suggested as a cause of sacroiliac joint dysfunction.1 The presence of sacroiliac joint dysfunction can create an apparent change in leg length, which may confound the accurate assessment of true leg length.[1]

Treatment Plan

I used a manipulative technique because the patient reported good results with manipulation performed 2 years previously by an osteopathic physician. Briefly, the technique involved placing the patient supine with the spine laterally flexed to the left. I stood on the right side of the patient. The patient's hands, were clasped behind his neck. I threaded one arm through the patient's clasped hands, rotating the upper trunk toward me. I then placed my free hand on the patient's ASIS that was furthest away from me. I applied a posterior force to the ASIS while the patient maintained full upper trunk rotation (Fig. 4).[11]

Results

After I performed the manipulative technique, the patient reported that his stiffness decreased when returning from forward bending and that his pain decreased during right side-bending. The four tests (ie, assessment of PSIS heights during sitting, positive standing flexion test, positive supine long-sitting test, and positive prone knee flexion test) were repeated to determine whether innominate bone rotation was present. After the manipulative technique, all four tests showed no evidence of innominate bone rotation. In addition, the patient reported no pain during the sacroiliac joint compression test. After performing the manipulation, I could not detect the presence of anatomical leg-length discrepancies by comparing the heights of the PSISs while the patient was sitting and then standing. The reliability of measurements obtained with this technique, however, has not been demonstrated.

After the manipulative technique, my second goal was to attempt to restore the patient's passive hip medial rotation by stretching. The patient was instructed to stretch his right hip lateral rotator muscles at least three to four times a day within pain tolerance (Fig. 5). He was instructed to lie prone and have someone gently rotate his right hip medially until he felt a slight stretch. The stretch was then supposed to be held constant until he no longer perceived a feeling of stretching. This process was to be repeated twice. The patient was instructed to stretch at least three times a day. Finally, I advised him to quit sitting and sleeping with the right hip in extreme lateral rotation.

Follow-up

The patient reported during his next visit, 2 days after the initial visit, that he was much improved. An Oswestry score showed significant improvement (a score of 16 versus the score of 34 on day 1). His trunk AROM remained painless in all directions. Left and right straight-leg-raising tests were painless at 95 degrees of hip flexion with the knee extended. Hip AROM and PROM were not measured because in my experience I have never found a change in hip AROM or PROM in less than 1 week. No further treatment was given at this time because of his improvement. No symptoms or signs indicative of sacroiliac joint dysfunction were found on reexamination.

The patient returned 1 week after the initial visit for reevaluation. He reported that he had no further pain or stiffness in his lower back. Walking, running, and moving from a sitting to a standing position were all painless. He also no longer noticed right-sided low back stiffness upon arising in the morning. An Oswestry questionnaire now showed a score of 2, indicating he had minimal perception of pain or disability in his low back. His hip PROM was improved, demonstrating 55 degrees of lateral rotation and 35 degrees of medial rotation on the right. His trunk AROM remained painless in all movements. About 3 months after the patient's initial visit, he returned for an unrelated problem. He reported that his low back remained completely painless. His right hip PROM now showed 50 degrees of lateral rotation and 45 degrees of medial rotation measured in the prone position. On examination, there remained no evidence of innominate bone rotation suggesting sacroiliac joint dysfunction.

Discussion

This case report demonstrates a possible relationship between asymmetrical hip rotation and sacroiliac joint dysfunction. Postures the patient frequently assumed may have led to the development of asymmetrical muscle lengths in the hip rotator muscles.[18] Habitual postures that place the hip in extreme lateral rotation during sitting and sleeping may have contributed to the asymmetrical hip rotation by shortening the hip lateral rotator muscles and lengthening the medial rotator muscles. Short lateral hip rotator muscles may have contributed to the innominate bone rotation that is supposed to develop in sacroiliac joint dysfunction.[23,24]

Some people believe that muscle length or strength imbalances may cause sacroiliac joint dysfunction[1-3,23-25] Muscles that attach to the pelvis may influence sacroiliac joint movement through their attachments.[5] Presumably, shortened lateral hip rotator muscles on the right side can posteriorly rotate the right innominate bone,[2,23,24] resulting in a concomitant anterior rotation of the left innominate bone.[11] Consequently, a combination of short right hip lateral rotator muscles and long hip medial rotator muscles may be responsible for creating antagonistic innominate bone rotations and manifest as sacroiliac joint dysfunction.24 Data to support this hypothesis, however, do not currently exist.

The initial treatment of the patient in this case report was aimed at restoring innominate bone rotation and decreasing the patient's pain. I have found the manipulative technique useful in instantly restoring the symmetry in innominate bones and in decreasing the patient's complaints of pain. I believe it is also important to try to identify and correct factors that may contribute to sacroiliac joint dysfunction. The patient's habit of maintaining extreme lateral rotation of the hip while sitting and sleeping may have contributed to his persistent low back pain. I believe that assessment of hip muscle length asymmetries and habitual postures is important in the management of patients who are believed to have a sacroiliac joint component of low back pain.

Pain in and around the region of the sacroiliac joint is common.[26] Although this case report suggests that the sacroiliac joint may contribute to low back pain, it does not necessarily imply that abnormal sacroiliac joint motion is the only source of low back pain. McGill[26] Suggests that pain around the sacroiliac joint may be the result of large stresses from the extensor muscles transmitted to the sacroiliac region. Further research is obviously necessary to understand the existence and potential origin of sacroiliac joint pain.

I cannot deny that this patient may have gotten better on his own without treatment; however, the reduction in episodes of low back pain gives some support for this method of treatment. A case report, however, cannot adequately assess what effect, if any, asymmetrical hip rotation may have on sacroiliac joint dysfunction or on low back pain. The limitations of a single case report necessitate the need for future controlled studies to determine the relationship between asymmetrical hip rotation and sacroiliac joint dysfunction.

Conclusion

This case report described a successful treatment of a patient who had low back pain by manipulating the sacroiliac joint, then restoring symmetrical hip rotation and eliminating extreme unilaterally rotated hip postures. Presumably, the extreme laterally rotated hip postures contributed to the asymmetrical hip AROM and PROM and low back pain in this patient. Prevention of chronic extreme lateral hip rotation in sitting and sleeping, as well as restoring hip rotation AROM and PROM, appeared to eliminate this patient's recurrent low back pain. Appendix. Symptoms and Signs Suggestive of Sacroiliac Joint Dysfunction 1. Pain and tenderness located around the PSIS(a) (see Fig. 1) 2. Pain with walking 3. Pain on straight leg raising above

70 degrees on the painful side 4. Pain with the FABER test on the painful

side 5. Pain with pelvic compression 6. Finding of uneven PSIS when sitting 7. Positive standing flexion test 8. Positive supine long-sitting test 9. Positive prone knee flexion test (a) PSIS=posterior superior iliac spine.

References

[1] Erhard R, Bowling R. The recognition and management of the pelvic component of low back pain and sciatic pain. Bulletin of the Orthopaedics Section, American Physical Therapy Association. 1977;2:4-15. [2] Porterfield A, DeRosa CP. Mechanical Low Back Pain: Perspectives in Functional Anatomy. Philadelphia, Pa: WB Saunders Co, 1991: 167. [3] Lee D. The Pelvic Girdle. Edinburgh, Scotland: Churchill Livingstone; 1989. [4] Woerman AL. Evaluation and treatment of dysfunction in the lumbar-pelvic-hip complex. In: Donatelli R, Wooden MJ, eds. Orthopedic Physical Therapy. Edinburgh, Scotland: Churchill Livingstone; 1989:421. [5] Daly JM, Frame PS, Rapoza PA. Sacroiliac subluxation: a common, treatable cause of low-back pain in pregnancy. Fam Pract Res J 1991;11:149-159. [6] Wadsworth CT. Manual Examination and Treatment of the Spine and Extremities. Baltimore, Md: Williams & Wilkins; 1988:76, 79, 171. [7] Bernard TN, Kirkaldy-Willis WH. Recognizing specific characteristics of nonspecific low back pain. Clin Orthop. 1987;217:266-280. [8] Cyriax JH, Cyriax PJ. Illustrated Manual of Orthopaedic Medicine. London, England: Butterworth & Co (Publishers) Ltd; 1983 [9] McKenzie RA. The Lumbar Spine: Mechanical Diagnosis and Therapy, Waikanae, New Zealand: Spinal Publications; 1981:49. [10] Maitland GD. Vertebral Manipulation. 4th ed. London, England: Butterworth & Co (Publishers) Ltd; 1977. [11] Cibulka MT, Delitto A, Koldehoff RM. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain: an experimental study. Phys Ther. 1988; 68:1359-1363. [12] Dunn EJ, Bryan DM, Nugent JT, et al. Pyogenic infections of the sacro-iliac joint. Clin orthop. 1976;118:113-117. [13] LaBan MM, Meerschaert JR, Taylor RS, et al. Symphyseal and sacroiliac joint pain associated with pubic symphysis instability. Arch Phys Med Rehabil. 1978;59:470-472. [14] Fairbank JCT, Pysant PB, Van Poortvliet JA, et al. influence of anthropometric factors and joint laxity in the incidence of adolescent back pain. Spine. 1984;9:461-464. [15] Mellin G. Correlations of hip mobility with degree of back pain and lumbar spinal mobility in chronic low-back pain patients. Spine. 1988; 13:668-670 [16] Ellison JB, Rose SJ, Sahrmann SA. Patterns of hip rotation range of motion: comparison between healthy subjects and patients with low back pain. Phys Ther. 1990;70:537-541. [17] Fairbank JCT, Davies JB, Coupar J, O'Brian JP. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980;66:271-273. [18] Gossman MR, Sahrmann SA, Rose SJ, Review of length-associated changes in muscle: experimental evidence and clinical implications. Phys Ther, 1982;62:1799-1808. [19] Bourdillon JF, Day EA. Spinal Manipulation. London, England: William Heinemann Medical Books Ltd; 1987. [20] Mennell JM. Back Pain: Diagnosis and Treatment Using Manipulative Techniques. Boston, Mass: Little, Brown & Co Inc; 1960:77. [21] Kendall FP, McCreary EK. Muscles: Testing and Function. 3rd ed. Baltimore, Md: Williams & Wilkins; 1983. [22] Potter NA, Rothstein JM. Intertester reliability for selected clinical tests of the sacroiliac joint. Phys Ther. 1985;65:1671-1675 [23] Macleod C. Exercises for lumbo-pelvic dysfunction. In: Proceedings of the Fifth Congress of the International Federation of Orthopaedic Manipulative Therapists. 1984:124-130. [24] Cibulka MT. Rehabilitation of the pelvis, hip, and thigh. In: Lehman R, Delitto A, eds. Clinics in Sports Medicine. Philadelphia, Pa: WB Saunders Co; 1989;8(4):777-803. [25] Vleeming A, Stoeckart R, Snijders CJ, The sacrotuberous ligament: a conceptual approach to its dynamic role in stabilizing the sacroiliac joint. Clin Biomech. 1989;4:201-203. [26] McGill SM. A biomechanical perspective of sacro-iliac pain. Clin Biomech. 1987;2:145-151.