Sacroiliac Joint Pain
Sacroiliac Joint (SIJ)
What is Sacroiliac Joint Pain?
Your Sacroiliac Joints (SIJs) are a critical linkage system between your lower spine and pelvis. The sacrum (tailbone) connects on the right and left sides of the ilia (pelvic bones) to form your sacroiliac joints. Due to the substantial weight-bearing forces placed upon this area, your sacroiliac joints are a reasonably stiff link between the pelvic bones and allow only a few degrees of movement. But that subtle movement is healthy and very important.
When your sacroiliac joints are not moving generally due to either stiffness or excessive movement, it is k as Sacroiliac Joint Dysfunction or SIJ Dysfunction, which commonly results in sacroiliac pain. You must have both normal SI Joint movement and muscle control around this area to avoid SI Joint pain and injury.
In some people, due to trauma, muscle weakness or just extra mobility, your sacroiliac joints can have excessive uncontrolled motion. This new motion allows your sacroiliac joints to adopt an abnormal or stressed joint position, which may result in sacroiliac joint pain.
What Causes Sacroiliac Joint Pain?
There are two main groups of sacroiliac dysfunction that cause SI Joint pain:
- Hypermobility / Instability / Dynamic Muscle Weakness
- Hypomobility / Stiffness
Hypermobility issues are the most common and will be discussed further in this article.
Hypomobility is typically associated with pathologies that tend to stiffen your sacroiliac joints such as in Ankylosing Spondylitis.
What Causes Sacroiliac Joint Hypermobility?
Your sacroiliac joints should move a few degrees for normal movement. Like most joints, your surrounding muscles act to stabilise your sacroiliac joints during stressful or vulnerable positions. The most crucial sacroiliac stabilising muscles are your deep abdominal core muscles and your deep gluteal muscle groups.
Your core muscles: specifically the transversus abdominis and oblique abdominals through their attachments to the iliac bones help closure of the pelvis and improves the position, control and stability of the sacroiliac joints. Researchers have discovered that contraction of the transversus abdominis muscle significantly stiffens and supports your sacroiliac joints. This improvement is more significant than that caused by an abdominal bracing action using all the lateral abdominal muscles (Richardson et al. 2002).
Further to this, researchers have discovered that your deep gluteal (buttock) muscles are essential for controlling the lateral and rear aspects of the pelvis and hip. (Grimaldi et al.). Any of your gluteal muscles can be weak and affect your SIJ control. Your gluteal muscles that can be affected include gluteus maximus, medius and minimus, plus a few other muscles that are less well known. These include piriformis, gemellus superior and inferior, obturator internus and even quadratus femoris.
When these muscle groups are weak or lack endurance, your sacroiliac joints are potentially vulnerable to excessive movement, which can lead to SIJ hypermobility dysfunction or instability and subsequent sacroiliac joint pain.
What Does Sacroiliac Joint Pain Feel Like?
Sacroiliac joint dysfunction can mimic numerous other back and hip injuries. It can cause lower back, hip, groin, buttock and sciatic pain. Sacroiliac pain is typically worse with standing and walking and improved when lying down, but not always. SIJ dysfunction can sometimes be painful to sit cross-legged and usually is painful to lie on your side for extended periods.
Bending forward, stair climbing, hill climbing, and rising from a seated position can also provoke sacroiliac pain, but this is variable. Sacroiliac pain increase during sexual intercourse and menstruation in women, but once again, this is highly variable.
How is Sacroiliac Joint Pain Diagnosed?
Accurately diagnosing sacroiliac joint pain & dysfunction can be difficult because SIJ symptoms can mimic other common back conditions. These include other mechanical low back pain conditions like facet joint syndrome or a bulging disc. Many other systemic conditions affect this region, including the reproductive and neurovascular structures.
X-rays can exclude some other pathologies, but an MRI is probably the diagnostic test of choice. MRI may show signs of sacroiliac joint inflammation or eliminate other potential pathologies, especially within the pelvis-hip complex.
A thorough physical examination by your experienced physiotherapist is still one of the best methods to assess for sacroiliac joint pain or instability thoroughly.
Is Exercise Good for Sacroiliac Pain?
Physiotherapists highly recommend an SIJ focused exercise protocol that is prescribed specifically to your assessment findings and the deficits identified. Weakness dominates as the leading cause of sacroiliac joint pain, so addressing your specific gaps usually is highly effective in both the short and long-term relief from SIJ pain.
Is Walking Good for Sacroiliac Pain?
Sacroiliac pain and how it responds to walking is variable. There does appear to be two distinct groups of SIJ dysfunction. One SIJ group ends to improve with walking. Sadly, there is another group that walking annoys. Your physiotherapist’s assessment is essential to determine which group you fall into and your treatment with be adapted accordingly.
Is Running Good for Sacroiliac Pain?
Running is a common cause of SIJ pain, so it is not recommended as a treatment option until your physiotherapist has assessed your dynamic muscle control and its ability to cope with running safely.
Does Stretching Help Sacroiliac Joint Pain?
Stretching of tight muscles within the hip-pelvis complex can sometimes help ease SI Joint pain. In particular, the piriformis muscle regularly overworks, being tight or overactive. However, you must ask WHY your piriformis repeated tightens. If it is the only muscle working effectively, albeit excessively, then the long-term solution to your sacroiliac joint pain may not be to stretch your piriformis muscle continuously.
Is Massage Good for Sacroiliac Joint Pain?
Massage, dry needling and trigger point therapy of tight muscles within the hip-pelvis complex can sometimes help ease SI Joint pain. As mentioned earlier, hypertonicity needs to be addressed along with muscle strengthening, especially in chronic or persisting SI Joint pain cases.
Can Weightloss Help Sacroiliac Joint Pain?
It makes sense that losing weight will decrease the SI Joint forces and increase your ability to for your muscles to control your body weight through the SI Joint complex. Weight-loss is a positive long-term solution.
How Long Does it Take for Sacroiliac Joint Pain to Go Away?
The success of sacroiliac joint pain treatment via pelvic joint realignment and subsequent dynamic stabilisation via an in-depth abdominal and hip core stability control programs is excellent. Often there is instantaneous relief and improvement in function after the successful symmetrical realignment of your SI Joints. This program will result in equal SI joint range of motion that then needs only requires effective muscular control to maintain. Relief on day one of your SI Joint treatment is a very favourable sign that your SI Joint position was causing your pain and dysfunction.
The long-term success then depends upon the effectiveness of the specific strengthening regime prescribed by your physiotherapist to support and control your sacroiliac joints.
Common SIJ & Buttock Pain SourcesThe following conditions may cause buttock pain or SIJ issues.
- Piriformis Syndrome
- Poor Hip Core Control
- Core Stability Deficiency
- DOMS - Delayed Onset Muscle Soreness
Lateral Hip Pain
SIJ & Buttock Pain Treatment Guidelines?While SIJ and buttock pain treatment will vary depending on your specific diagnosis, your physiotherapist will have the following aims.
PHASE I - SIJ Pain Relief & Joint ProtectionPain ReliefWhile pain relievers or anti-inflammatory medications are often prescribed for acute SIJ dysfunction they will not address the true cause of SIJ pain. Chronic cases of SIJ dysfunction should be thoroughly assessed by a healthcare practitioner who has a comprehensive understanding of the biomechanics and muscular control of your SIJ, pelvis and hip complex. Managing your sacroiliac pain is the main reason that most people seek treatment for sacroiliac joint dysfunction. In truth, it was actually the final symptom that you developed and should be the first symptom to improve in most cases. If this is the case, the prevention of a recurrence becomes your priority.Natural short-term pain relief can often be achieved by using ice or heat packs applied to your SIJ's.Reduce InflammationManaging your inflammation. Sacroiliac joint inflammation it best eased via ice therapy and techniques or exercises that unload the inflammed structures. Your doctor may recommend a course of non-steroidal anti-inflammatory drugs such as ibuprofen. Some seronegative arthritis condition can predispose you to sacroiliitis. Special blood tests can be arranged by your doctor to assist diagnosis in these conditions. Prolonged morning stiffness is a common complaint. See Ankylosing Spondylitis.SIJ Protection & SupportSacroiliac joint instability occasionally requires additional passive support until your muscles successfully control the joint. Supportive taping is often beneficial during the initial pain reduction phase.SIJ Stability BeltLonger-term instability may be managed with a sacroiliac joint stabilisation belt. However, an exercise protocol to specifically address your SIJ issue is normally more effective.If you have any questions please seek the advice of your physiotherapist.
PHASE II - Restoring Normal ROM and Strength. Early Hip Core Exercises.As your SIJ pain and inflammation settle, your physiotherapist will turn their attention to restoring your normal pelvic joint alignment and normalisation of the dynamic muscle control that affects the SI Joints.Your physiotherapist may commence you on a lower abdominal core stability program to facilitate your important muscles that dynamically control and stabilise your lower back and pelvis. They will also implement a similar activation and strength program that addresses your deep gluteal muscles. These muscles are sometimes referred to as your hip core muscles. Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises for your specific needs.
PHASE III - Restoring Full FunctionAs your sacroiliac joint dynamic control improves, your physiotherapist will turn their attention to restoring your normal pelvic alignment and maintaining sacroiliac joint range of motion during more functionally stressful positions and postures plus work on your muscle power, proprioception, balance and gait (walking pattern). Depending on your chosen sport or activities of daily living, your physiotherapist will aim to restore your SIJ function to safely allow you to return to your desired activities.Everyone has different demands for their sacroiliac joints that will determine what specific treatment goals you need to achieve. For some, it is simply to walk around the block. Others may wish to run a marathon. Your physiotherapist will tailor your sacroiliac joint rehabilitation to help you achieve your own functional goals.
PHASE IV - Preventing a RecurrenceSacroiliac joint dysfunction does have a tendency to return if a thorough muscle control program is not undertaken. The main reason it is thought to be chronic and specific muscle weakness. Your physiotherapist will assist you in identifying the best exercises for you to continue indefinitely or periodically.In addition to your muscle control, your physiotherapist will assess your SIJ, spine, hip and lower limb biomechanics and correct any deficits that may predispose you to SIJ pain and dysfunction. Fine-tuning and maintenance of your sacroiliac joint stability and function are best achieved by addressing any deficits and learning self-management techniques. Your physiotherapist will guide you.
What is Physiotherapy Treatment?
Physiotherapists help people affected by illness, injury or disability through exercise, manual joint therapy, soft tissue techniques education and advice. Physiotherapists maintain physical health, help patients to manage pain and prevent disease for people of all ages. Physiotherapists help to encourage pain-relief, injury recovery, enabling people to stay playing a sport, working or performing activities of daily living while assisting them to remain functionally independent.
There is a multitude of different physiotherapy treatment approaches.
Acute & Sub-Acute Injury Management
Hands-On Physiotherapy Techniques
Your physiotherapist's training includes hands-on physiotherapy techniques such as:
- Joint Mobilisation (gentle joint gliding techniques)
- Joint Manipulation
- Physiotherapy Instrument Mobilisation (PIM)
- Minimal Energy Techniques (METs)
- Soft Tissue Techniques
Your physiotherapist has skilled training. Physiotherapy techniques have expanded over the past few decades. They have researched, upskilled and educated themselves in a spectrum of allied health skills. These skills include techniques shared with other healthcare practitioners. Professions include exercise physiologists, remedial massage therapists, osteopaths, acupuncturists, kinesiologists, chiropractors and occupational therapists, just to name a few.
Your physiotherapist is a highly skilled professional who utilises strapping and taping techniques to prevent and assist injuries or pain relief and function.
Alternatively, your physiotherapist may recommend a supportive brace.
Acupuncture and Dry Needling
Many physiotherapists have acquired additional training in the field of acupuncture and dry needling to assist pain relief and muscle function.
Physiotherapists have been trained in the use of exercise therapy to strengthen your muscles and improve your function. Physiotherapy exercises use evidence-based protocols where possible as an effective way that you can solve or prevent pain and injury. Your physiotherapist is highly-skilled in the prescription of the "best exercises" for you and the most appropriate "exercise dose" for you depending on your rehabilitation status. Your physiotherapist will incorporate essential components of pilates, yoga and exercise physiology to provide you with the best result. They may even use Real-Time Ultrasound Physiotherapy so that you can watch your muscles contract on a screen as you correctly retrain them.
- Muscle Stretching
- Core Exercises
- Strengthening Exercises
- Balance Exercises
- Proprioception Exercises
- Real-Time Ultrasound Physiotherapy
- Swiss Ball Exercises
Biomechanical assessment, observation and diagnostic skills are paramount to the best treatment. Your physiotherapist is a highly skilled health professional. They possess superb diagnostic skills to detect and ultimately avoid musculoskeletal and sports injuries. Poor technique or posture is one of the most common sources of a repeat injury.
Aquatic water exercises are an effective method to provide low bodyweight exercises.
Sports physio requires an extra level of knowledge and physiotherapy skill to assist injury recovery, prevent injury and improve performance. For the best advice, consult a Sports Physiotherapist.
Women's Health Physiotherapy is a particular interest group of therapies.
Not only can your physiotherapist assist you in sport, but they can also help you at work. Ergonomics looks at the best postures and workstation set up for your body at work or home. Whether it be lifting technique improvement, education programs or workstation setups, your physiotherapist can help you.
Plus Much More
Your physiotherapist is a highly skilled body mechanic. A physiotherapist has particular interests in certain injuries or specific conditions. For advice regarding your individual problem, please contact your PhysioWorks team.
Pins and Needles - Paraesthesia
What Causes Pins & Needles?
A moderately pinched nerve is the most common cause of "pins and needles". Pins and needles are referred to as "paraesthesia" in the medical community. Did you know that feeling "pins and needles" can be a worse sign than having pain in your arm or leg? The reason is that you can't even feel pain anymore when you significantly squash the nerve.
Even worse than "pins and needles" is "numbness" or "anaesthesia", which is a total lack of sensation. You will experience anaesthesia when there is severe nerve compression. Anaesthesia or numbness that persists for more than a few hours can be a sign of permanent nerve compression. Please seek prompt medical attention to prevent the nerve from permanent damage and the muscles it innervates to weaken drastically.
The majority of pinched nerves and nerve compressions are only transient and quickly reversed with early treatment. However, neglect can lead to permanent nerve compression injuries, which may never recover.
Common Causes of Pinched Nerves
The most common forms of nerve compression are in the spinal joints where either a disc bulge or a bony arthritic spur can irritate and compress the nerve. Compressions can also occur as the nerve passes through or around muscles. Your physiotherapist will know where to look.
How Can You Fix "Pins and Needles"?
If you know of someone who is experiencing chronic or permanent "pins and needles", "numbness" or "muscle weakness", please encourage them to seek urgent professional advice. The secret to quick success is the correct diagnosis. A highly trained health practitioner such as your physiotherapist or doctor is your best port of call.
What is Therapeutic Ultrasound?Therapeutic ultrasound is an electrotherapy modality which has been used by physiotherapists since the 1940s. Via an ultrasound probe through a transmission coupling gel in direct contact with your skin, ultrasound waves are applied. Therapeutic ultrasound may increase:
- healing rates
- tissue heating
- local blood flow
- tissue relaxation
- scar tissue breakdown.
How Could Ultrasound Help?Ultrasound increases local blood flow. This increase may help to reduce local swelling and promote soft tissue healing rates. A higher power density may soften scar tissue.
Specific Ultrasound UsesMastitis or blocked milk ducts successfully respond to therapeutic ultrasound. The effect is quite dramatic, with improvement within 24 to 72 hours.The most common conditions treated with ultrasound include soft tissue injuries such as muscle, ligament injuries or some tendinopathies.Phonophoresis uses ultrasound in a non-invasive way of administering medications to tissues below the skin. This method may assist patients who are uncomfortable with injections. With phonophoresis, the ultrasonic energy forces the drug through the skin.
What is an Ultrasound Dose?A typical ultrasound treatment will take from 3-10 minutes. Where scar tissue breakdown is the goal, this treatment time could be much longer. During the procedure, the head of the ultrasound probe is in constant motion. If kept in continuous motion, the patient should feel no discomfort at all.Some conditions treated with ultrasound include soft tissues injuries such as muscles or ligament injuries, tendinopathy, non-acute joint swelling and muscle spasm.
How Does an Ultrasound Work?A piezoelectric effect, caused by the vibration of crystals within the ultrasound head of the probe creates the sound waves. The ultrasound waves generated then pass through the skin cause a vibration of the local soft tissues. This repeated cavitation can cause a deep heating locally though usually no sensation of heat will be felt by the patient. In situations where a heating effect is not desirable, an athermal application occurs. Athermal doses are typical during acute fresh injury and the associated acute inflammation.
When Should Ultrasound be Avoided?Contraindications of ultrasound include:
- local malignancy,
- over metal implants,
- local acute infection,
- vascular abnormalities,
- active epiphyseal regions (growth plates) in children,
- over the spinal cord in the area of a laminectomy,
- over the eyes, skull, or testes
- and, directly on the abdomen of pregnant women. Treatment ultrasound differs from diagnostic ultrasound!
Core Stability MusclesThe deep core stability muscles of the lower spine include:
- Transversus Abdominis (TA)
- Multifidus (MF)
- Pelvic Floor (PF)
Transversus AbdominisThe Transversus Abdominis (TA) is the deepest abdominal muscle. It is the "corset muscle" of the spine and pelvis. In the typical situation, TA contracts in anticipation of body motion to guard the spinal joints, ligaments, discs and nerves.
MultifidusMultifidus (MF) muscles are very short muscles running from the transverse processes (on the sides) of one vertebra up to the spinous process (the middle of the back) of the next vertebra upwards. Their primary function is back stability. They do not produce an extensive range of movement, but work to provide small, "fine-tuning" postural changes, all day long.
Pelvic Floor & DiaphragmThe TA and the MF work in conjunction with your pelvic floor and diaphragm to make a flexible but stable region around your lumbar spine. It is this ability to stabilise your lumbar spine in its many positions that enable you to overcome back problems and reduce your chances of a reoccurrence.
What Are The Ideal Core Exercises?Your deep core stability muscles retraining uses specific low-level activation exercises. While a very skilled physiotherapist who has training in deep core activation can observe and palpate for the correct muscle contraction, the best way is to see them working on a real-time ultrasound scan.Real-Time Ultrasound Physiotherapy guidance allows you to see how your muscles are contracting in real-time. This visual feedback will enable you to correct your specific deep core muscles inside your stomach, lower back, and pelvic floor as you attempt to contract those muscles.
Beware of “Core Stability” Exercises!The fitness industry is full of fitness instructors who profess to know how to activate your core stability muscles. Unfortunately, the wrong core exercises will do you harm. Most progress your core exercises far too quickly and bypass these critical muscles to strengthen your outer abdominal muscles further and leave your deep core muscles weak. Research evidence has found that this renders you vulnerable to lower back pain and injury.
Core Stability vs PilatesThe whole 'core stability' phenomenon started back in the 1920s with a chap named Joseph Pilates, who's exercise regimes have become quite trendy in the last ten years.Pilates talked about developing a 'girdle of strength' by learning to recruit the deep-trunk muscles. Even without complete knowledge of anatomy and the benefits of the latest muscle activity research, he was aware of the importance of these deep muscles and their supportive effects.Put simply; core stability training targets explicitly the smaller and deeper back and stomach muscles. Once recruited, these muscles control the position of the spine during dynamic movements of your body.
Is Pilates for Everyone?Sadly, No! Exercise programs that aim to develop your deep core strength can often do just the opposite. The most common reason for injury and back pain is the incorrect timing of core muscle recruitment. Pilates, Yoga, gym strengthening and other forms of exercise place high demands on your core stability system. Abnormal core muscle recruitment order increases your injury chance proportion with the exercise difficulty.Remember, if you build a tower on a weak foundation, it will eventually topple. Look what happened to the Leaning Tower of Pisa. It's got lousy core stability! The same goes for your core stability muscles.However, recruiting the deeper core muscles before your superficial layers just like adding floors to a sturdy skyscraper and your back will be healthy and pain-free forever.
Why is it Important to Specially Retrain your Core Stability Muscles?Once the core muscles become weak, and their timing is incorrect, you can experience prolonged back pain and are at much higher risk of re-occurrence. Research has identified that the order of core muscle recruitment is one of the most critical factors in the prevention or resolution of pain. Real-Time Ultrasound Physiotherapy has proven particularly useful to correct the muscle recruitment order.To solve your back pain and to reduce your re-injury risk, you must retrain these muscles back to an appropriate level for your needs. If you are relatively sedentary, you may only need a low level of control, however, if you are a high-level sportsperson or a manual worker you will need to work up to a much higher level of core strength.
What Should You Expect?In the initial stage, you need to be able to activate these muscles consciously and incorporate them into an exercise program. A lot of people find it difficult to isolate these muscles and need help to be able to activate them effectively.Research has discovered that real-time ultrasound-guided treatment is the most effective way to retrain an isolated and well-timed core stability contraction successfully.
Common Sources of Spinal Pain & Injury
- Neck Pain - Cervical Spine
- Upper Back Pain - Thoracic Spine
- Lower Back Pain - Lumbar Spine
- Sacroiliac Pain - SIJ
- Scheuermann’s Disease
- Spinal Stenosis
- Rib Stress Fracture
Nerve-related / Referred Pain
Why Do Physiotherapists Prescribe You Exercises?The prescription of exercise appropriate to you and your injury or fitness level is one of the many professional skills of a physiotherapist. Whether you have suffered an acute injury, chronic deconditioning or are recovering from surgery, the correct exercise prescription is essential. That's why your physiotherapist's knowledge and skills will personalise your exercise dose.Your physiotherapist not only is educated in injury diagnosis but also exercise physiology or the science of exercise. This training enables your physiotherapist to assess and diagnose your injury, plus also to prescribe injury, fitness or age-appropriate activities targeted to you now.
What Exercises Should You Do?Your exercises shouldn't be painful. Please take caution with some overzealous exercise prescribers who believe that the more painful the activity, the better. Thus simply isn't true—notably, the frail, immunosuppressed, deconditioned or post-operative person.You'll find that your physiotherapist will thoroughly examine you and prescribe a series of exercises suitable for you in quantities that will not injure you further. Please seek an exercise expert, such as your physiotherapist, when you are planning your rehabilitation.
What Happens When You Stop Exercises?Without some simple exercises, we know that specific muscles can become weak. When these supporting muscles are weak, your injured structures are inadequately supported and predispose you to linger symptoms or further injury. You can also over-activate adjacent muscles that may lead to further damage.It is also essential to understand that even if you are "in good shape", you may have crucial but weak localised or stability muscles. When you have an injury, you should perform specific exercises that specifically strengthen the muscles around your injury and the adjacent joints. Your physiotherapist will assess your muscle function and prescribe the right exercises specific for your needs.The exercises prescribed will usually be relatively simple, and do not require any special weights equipment, and can be performed safely at home.
Would You Stop Your Daily Prescription Drugs?Your physiotherapist will prescribe your individualised dose or exercises. They are using their professional expertise to optimise your exercise dose. Would you just stop taking your regular blood pressure medication because you were too busy or didn't think it was working? We would hope not!Exercise, when prescribed by an expert such as your physiotherapist, should be treated as your recommended dose. Just like when you don't take your blood pressure medication, you can't expect the drugs to work of you don't take it as prescribed by your health professional.So, next time you skip your "exercise dose" just remember that you are not putting your health first. If you have any questions, please contact your Physio Works physiotherapist for your best care.
Private Health Insurance Rebates
PhysioWorks Physiotherapy and Remedial Massage are more affordable than you think. Your Private Health Insurance (PHI) usually pays for the majority of your treatment fees, leaving you with only a small gap payment.
However, Private Health Funds do vary their rebates payable depending upon the level of cover that you have taken. Some funds have kept up with the costs of modern medicine whereas, sadly others haven't, with rebates similar to what they were a decade ago.
HICAPS - Instant Health Fund Claims
Most health funds are members of the HICAPS instant claims system. Swipe your health insurance card at our reception counter, and you can instantly claim your physiotherapy treatment via our online Hicaps System. Remedial Massage is claimable via Hicaps for some but not all funds. For more information, please visit Hicaps for the latest funds which can use their instant claiming system.
Private health insurance rebates are available for all of our physiotherapists. Instant claims are possible via our in-practice Hicaps system.
- All Private Health Insurance Funds including BUPA, Medibank Private, HCF
- For a full list of Hicaps instant claim funds see here: Hicaps Funds
- HCF More for Muscles Program
PhysioWorks practitioners are registered providers for government, Workcover and insurance companies including:
- Australia Post; Coles Myer; Woolworths
- Department of Veterans' Affairs
- CTP & Sports Insurers