Research into the sacroiliac joint (SIJ) as the cause of low back pain (LBP) was plentiful in the early 1900s, but lost focus on the SIJ with the discovery of the herniated intervertebral disc (herniated nucleus pulposus). When it was finally apparent that the disc was not the center of the problem, disc research was set aside by several varieties of innovative rhetoric, which further obscured the focus on a specific cause of LBP.
A personal narrative is necessary. In 1964, I saw a typical patient with acute LBP and I did everything I could to relieve her with heat, electrical stimulation, massage, and posture training, but nothing helped her. Of course, I made her another appointment. She called the next day to cancel her appointment because she was free of pain. I asked her what she did to relieve her pain because I had not helped her and perhaps I could learn from her experience.
She reluctantly told me, “I fell off of my tractor.” I suspected that having an office full of tractors was not going to help much, but I realized that LBP was most likely to be a reversible, biomechanical problem and if I could ascertain the nature of this problem I could have patients free of pain immediately. I had the basic mechanism within a few weeks.
I knew that back pain can be caused by lifting, bending, lowering, shoveling, sweeping, posture, pregnancy, and weak, protruding abdominal muscles, all of which are caused by an anterior shift in the line of gravity with an anterior rotation of the innominates. I reasoned that if an anterior innominate rotation caused pain and dysfunction then a manual posterior innominate rotation should relieve the pain. Most importantly I learned that anterior innominate rotation altered pelvic structure in such a way as to cause the legs to appear to lengthen with dysfunction and to shorten with a correction in manual posterior innominate rotation. And it did and does. After a few years I had analyzed the basic mechanics and made measurements of the posterior superior iliac spine (PSIS). In the late 1960s, I wrote it up and sent it in to the physical therapy journal. They reviewed it and returned it 4 times before asking me to send it to another journal, which I did. Evidently they had no use for a method of treatment that brought immediate relief of pain (Figures 1–7).
MECHANICS OF DYSFUNCTION
Low back pain is essentially always caused by an anterior shift in the line of gravity with loading. Lifting, bending, sweeping, vacuuming, a pendulous abdomen, forward head, etc, are all causative movements. Pathology in posterior innominate rotation cannot occur because posterior innominate rotation drives the sacrum caudad.
Leg lengthening and shortening
An anterior shift of the line of gravity over the acetabular axis changes several critical relationships. In 1906, McConnell and Teall1 described the manner in which the pelvis moves up posteriorly on the sacrum and downward anteriorly causing an apparent increase in leg length, which can be demonstrated by examining the heels or approximating the medial malleoli with the patient supine.1 Chamberlain2 identified this dysfunction with stereographic roentgenograms in 1930 (Figures 8–11).
Sciatica was found to be caused by dysfunction in the SIJ at least 90 years ago when in 1928 Yeoman reported that sacroiliac arthritis was responsible for 36% of the cases of sciatica.3 In 1925, Danforth and Wilson4 attempted to determine the relationship between the SIJ and the sciatic nerve, but concluded that as there was no canal nor semblance of a canal anywhere near the joint the SIJ could not be at fault. However, no consistent test could be found and no bony axis of rotation has been described or measured.5 Sciatica was also associated with the disc, so when sciatica was found, the SIJ was eventually ignored and the disc was accepted as the source of sciatica (Figure 12).
Palpable trigger points are found in these areas. This dysfunction of the SIJ is responsible for the deep buttock pain at the posterior inferior iliac spine (PIIS) always found with sacroiliac joint dysfunction (SIJD). A trochanteric bursitis and pain down the iliotibial band may also occur depending upon the degree of shear and separation of the gluteus maximus (Figures 13 and 14).
Abdominal pain with LBP
Sacral-subluxation may also cause abdominal pain at Baer's sacroiliac point, which is on a line from the umbilicus to the superior iliac spine, 2 inches from the umbilicus.6–8 I saw a patient who had LBP with abdominal pain for 4 years. She had both ovaries removed with no relief. Both the abdominal pain and the LBP were immediate relieved with a manual bilateral posterior innominate rotation (Figure 15).
An asymmetrical anterior innominate rotation with a long leg and a high iliac crest can cause a scoliosis without pain in prepubertal children, when standing or sitting. This must be examined for when doing scoliosis checking. This can be corrected immediately with a manual posterior innominate rotation correction. The parent must be instructed in follow-up.
The anterior innominate rotation will also approximate the ischial tuberosities toward the sacrum, thus slightly loosening the muscles of the pelvic floor, and cause some degree of incontinence. A few months following one of my workshops, I received an e-mail from one of the therapists who attended. She told me that she had been teaching incontinence training for women in Hong Kong. She also told me that frequently following my corrections for LBP the patient no longer needed the incontinence training.
The pudendal nerve from the sacral plexus passes next to the piriformis and innervates both the anal sphincter and the external urethral sphincter, thus adding another degree of complexity to the Piriformis syndrome. Incontinence usually reverses with a correction in manual posterior innominate rotation in a day or so.
EVALUATION AND MANAGEMENT
At the initial meeting because acute and chronic can have so many different issues, it is imperative to first establish the presence or absence of SIJD. With the patient standing or prone, first locate both PSIS and the let your fingers drift caudad and somewhat medially to the PIIS. With dysfunction the long posterior iliac ligament will be tender in this area. When you reach the PIIS, this axis point will be very tender, usually one side more than the other.
With the patient lying supine and the operator at the foot of the table, hold both feet so that the malleoli are approximated in the midline and compare the relative leg length. Take note that one side may be longer or shorter than the other. Stand to one side of the patient and do a passive straight leg raise to about 35° to 40° and put traction to tolerance on the leg at that angle. Gently lower the leg and check the relative leg length again. That leg will probably appear to shorten from 1 to 1.5 cm or more. Move to the other side and do the same procedure and that leg will also appear to get shorter. Move back to the first leg and repeat the procedure. Keep repeating right to lift passive straight leg raise to each leg as long as a shortening of the leg appears.
Next have the patient hold on knee-to-chest with both arms wrapped around it and do a strong isometric hip extension. Check the comparative leg length again. Did it appear to shorten anymore? Have the patient repeat the isometric hip extension on the other side and check the leg length. Keep repeating until neither leg shortens anymore.
Instruct the patient in a self-correction exercise and have them repeat it every few hours until the next appointment. The next time you see the patient have them demonstrate the exercise that you had instructed them in as it may be necessary to repeat the instructions. Now repeat your corrections, checking leg length again, and instruct them in a strong isometric correction. Make another appointment only if the patient wants to return. Give them a printed booklet of instructions and have them return if they cannot properly correct. I used to average 2.8 treatments per patient.
The patient must be instructed in how to prevent recurrence of this problem by supporting his pelvis up with his abs whenever he leans forward to perform any task. Joint instability can be controlled with an SIJ belt worn just below the crests and above the trochanters. We have had some good results with injections of platelet-rich plasma into the PIIS.
Initial innominate movement is a weight shift to the side of loading and then a posterior rotation of the thigh to be lifted on an axis through the pubic symphysis, which causes a lateral sacral flexion and an oblique sacral axis. Note also how movement of the PSIS pivots on the transverse loading axis at the same time oblique sacral movement occurs on the force-dependent oblique axis.
As the pathological force of anterior innominate rotation can cause multiple symptoms immediately, you can expect that a corrective force in manual posterior innominate rotation to relieve all of those symptoms immediately. Pathology of the SIJ s is far more complex and affects many more patients than previously suspected, but can be easily detected merely by palpating for pain at the PIIS. A manual correction in posterior innominate rotation is vastly more simple and effective than other methods of treatment, but is seldom prescribed.
Lack of appropriate education and the substitution of creative rhetoric for more accurate and appropriate pathology have forced a lack of research on the SIJs and the pelvis. This has compelled some insurance companies to avoid payment on the diagnosis and treatment of dysfunction of the SIJs. There are some leaders in this field who are reluctant to publish sound research for fear that any effective research may prove detrimental to the distribution of the huge amount of funds presently generated for the treatment and research of LBP.
1. McConnell CP, Teall CC. The Practice of Osteopathy. 3rd ed. Kirksville, MO: Journal Printing Co; 1906.
2. Chamberlain WE. The symphysis pubis in the Roentgen Examination of the sacroiliac joint. Am J Roentgenol. 1930;24:621–625.
3. Yeoman W. The relation of arthritis of the sacroiliac joint to sciatica. Lancet. 1928;2:1119–1122.
4. Danforth MS, Wilson PD. The anatomy of the lumbo-sacral region in relation to sciatic pain. J Bone Joint Surg. 1925;7:109–160.
5. Platt H. Backache—sciatica syndrome and intervertebral disk. Rheumatism. 1948;4:218.
6. Baer WS. Sacro-iliac strain. Bull
Johns Hopkins Hosp. 1917;28:159.
7. Mennell JB. The Science and Art of Joint Manipulation: The Spinal Column. 2nd ed. London, England: J & A Churchill Ltd; 1952:90.
8. Norman GF. Sacroiliac disease and its relationship to lower abdominal pain
. Am J Surg. 1968;116:h54–h46.
9. Rauber-Kopsch F: Lehrbuch and Atlas der Anatomie des Menschen. Edited by Kopsch F, Thierme G, Leipzig 1940–43.
10. DonTigny RL. Measuring PSIS movement. Clin Manag. 1990;10:43–44.