Sacroiliac Joint Dysfunction (SIJD) “Fixation” PRT Treatment
A patient who complains of low back or lower extremity pain should be checked for an anterior innominate rotation, or also known as a pelvic shear or downslip of the innominate. The majority of low back pain complaints I have encountered over the years coupled with other biomechanical complaints of the lower extremity are often the result of a pelvic bone that is “stuck” or is out of place. The most common seen is the anterior innominate rotation or downslip position. We have found without addressing the neurochemical bonding with PRT prior to use of other manual therapies, e.g., muscle energy, the “fixation” returns. We have honed our treatment protocol of this nasty and resistant to treat condition with over thousands of successful treatments and working to address the root cause of the condition.
Dysfunction at the sacroiliac joint can arise from a multitude of factors,1-3 which may affect its relationship and kinematics with the ilium resulting in sacroiliac joint dysfunction (SIJD). However, there is still much debate on how much movement occurs at the sacroiliac joint and what factors are most causative for disruption of its movement.3 Qureshi and colleagues2 have recently demonstrated that somatic dysfunction may cause an innominate rotation of the ilium or sacral torsion when present. Other factors that may lead to disruption of the joint’s kinematics may be lumbar disc pathology, leg length discrepancy, overload of surrounding soft tissue structures due to gait abnormalities (e.g., late stance pronation, toe out gait), muscular imbalance and pelvic trauma. Even though it is estimated that upwards of 30% of all non-specific low back pain (LBP) is the result of SIJD, clinical assessment has proven to be challenging as well as its treatment.4 However, a common clinical finding at the Positional Release Therapy Institute among patients with non-specific LBP has been the presence of innominate rotations, primarily, an anterior innominate rotation. An anterior innominate rotation presents with the ipsilateral ilium shifted downwards and medially in relation to the contralateral ilium.5 When assessing the presence of an anterior innominate rotation, the anterior superior iliac spine of the affected ilium will present lower and rotated more medially upon palpation and visual inspection.1,5 Additionally, it is common that the affected ilium will not rotate downwards adequately when the patient attempts to raise their knee upwards, which is often assessed with the March or Gillet Test. 5
Common Signs and Symptoms
Common Differential Diagnoses
- Non-specific low back pain, often greater on the fixated or dysfunctional side
- Pain radiating into the groin from the anterior hip
- Pain at the posterior and lateral hip
- Point tenderness at the sacroiliac joint, buttock and inferior pubis or ischium
- Pain with stair climbing, lunging or trunk flexion
- An audible and sensation of a click or pop with ipsilateral standing hip flexion
- Weak groin and abdominal musculature
- Pain with active hip adduction at the pubis
- Positive Gillet or Modified March Test
- Increased dynamic knee valgus with anterior reach
- Pelvic somatic dysfunction
- Leg length discrepancy
Clinician Therapeutic Interventions
- Sacral fusion
- Femoral neck stress fracture
- Athletic Pubalgia
- Osteitis Pubis
- Tendon avulsion
- Symphsis non-union
- Rectus abdominis tear
- Sports hernia
- Lumbosacral pathology
- Calcific tendinitis
- Facet joint disease
- Lateral hip bursitis
- Iliopsoas pathology
- Compression neuropathies
- Assess gait biomechanics of the patient with high speed film analysis if possible
- Assess for leg length discrepancy clinically as well as with radiograph, if possible
- Assess lumbopelvic complex for asymmetry, motion and strength deficits
- Implement a progressive hip and core strengthening program, particularly for the adductor and abdominal musculature
- Consider use of an orthotic to address significant leg length discrepancy as well as to unload the hip if the patient demonstrates gait abnormality
- Consider the following treatment sequence:
- Positional Release Therapy (PRT)
- Thermal ultrasound or diathermy to the affected SI joint
- Grade III Maitland joint mobilization at the base of the sacrum, then at the lumbosacral junction
- Pelvic muscle energy (MET), e.g., bicycle, adductor procedure
- Long axis distraction or HVLA (high velocity low amplitude) manipulation if a pelvic cavitation is not elicited during MET.
Patient Self-Treatment Interventions
PRT Treatment Points & Recommended Sequencing
- Perform self sacroiliac joint mobilizations and muscle energy daily to encourage continued movement of the joint articulation
- Self-release the hip adductors and abductors, abdominals and hip flexor group daily
- Avoid sport and ADL activities that irritate the joint until stability of the joint and functional strength has been regained
- Apply thermal modalities to the joint to promote blood flow
- Adductor Magnus (Inferior Pubis)
- Adductor Longus (Superior Pubis)
- Sartorius Tendon
- Psoas Major
- Sacroiliac Joint
- Gluteus Medius
- Quadratus Lumborum
- Errector Spinae
- Center VIP, Springs C, Center F. Evaluation of sacroiliac joint interventions: A systematic appraisal of the literature. Pain Physician. 2009;12:399-418.
- Qureshi Y, Kusienski A, Bemski JL, Luksch JR, Knowles LG. Effects of somatic dysfunction on leg length and weight bearing. The Journal of the American Osteopathic Association. 2014;114(8):620-630.
- Gnat R, Spoor K, Pool-Goudzwaard A. The influence of simulated transversus abdominis muscle force on sacroiliac joint flexibility during asymmetric moment application to the pelvis. Clinical Biomechanics. 2015;30(8):827-831.
- Adhia DB, Milosavljevic S, Tumilty S, Bussey MD. Innominate movement patterns, rotation trends and range of motion in individuals with low back pain of sacroiliac joint origin. Manual therapy. 2015 (Article in Press). Available at: http://www.sciencedirect.com/science/article/pii/S1356689X15001332
- Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesthesia & Analgesia. 2005;101(5):1440-1453.
And Now the News!
Human Kinetics Publishing Expected Text Release Date: April 2016
Clinical Guide to Positional Release Therapy
is an invaluable resource for those who desire to learn, practice, and perfect the art of positional release therapy (PRT) to gently and successfully treat patients of all ages experiencing acute to chronic somatic dysfunction.
Author Timothy E. Speicher, President of the Positional Release Therapy Institute, utilizes contemporary science and evidence-based practice to provide health care practitioners including athletic trainers, physical therapists, massage therapists, and chiropractors with a proven manual of PRT treatment techniques. The text is also suitable for students enrolled in upper-level courses in athletic training, physical therapy, and massage therapy programs.
Lisa Hall-Bostick, ATC, LAT, PRT-c (Montana) , Valerie Rodarte, MS, ATC, PRT-c (California), Michael Buonopane, MS, ATC, PRT-c (Boston), Smokey Fermin, MS, ATC, PRT-c (Idaho), Russell Baker, DPT, AT, LAT, PRT-c (Idaho)
Trademarks Filed with U.S. Patent and Trademark Office
Dr. Russell Baker, DAT, AT, LAT, PRT-c
- Positional Release Therapist™
- Certified Positional Release Therapist (PRT-c™)
- Positional Release Therapy Institute (PRT-i™)
Dr. Rusty Baker earned Bachelor of Science in Human Sciences and Master of Science in Physical Education degrees from Florida State University, a Master of Science in Kinesiology degree from California State University-Fullerton, and his Doctor of Athletic Training degree from the University of Idaho. Currently, he is a clinical assistant professor and the Clinical Education Coordinator (CEC) for Athletic Training Education at the University of Idaho (UI). Dr. Baker joined the faculty at UI in May of 2013 and teaches in the professional Master of Science in Athletic Training (MSAT) and post-professional Doctor of Athletic Training (DAT) programs. Prior to arriving at UI, Dr. Baker spent 6 years as an assistant professor and the CEC for the professional MAST program at California Baptist University. His primary research interests are the evaluation and treatment of musculoskeletal pathologies and effectiveness of manual therapies. Over the past few years, he has co/authored more than 25 peer-reviewed publications and 50 conference presentations. As a clinician, Dr. Baker has provided athletic training services at the NCAA Division I, NCAA Division II, NAIA, high school, and professional levels.
Colleen Neider, LMT, LPN has joined our clinical practice in Ogden Utah. Colleen is a licensed massage therapist with 20 years of experience in the nursing field and during this time has also been a yoga and cycling instructor. She has worked in various medical settings including cardiology and family practice. She graduated from Myotherapy College of Utah and specializes in Positional Release Therapy, Medical-Therapeutic Massage and Thai Massage. Colleen has worked both as an administrative and clinical assistant at the Positional Release Therapy Institute and teaches various strength and conditioning classes at PRT-I, including the Run Strong Core ProgramTM. She is a competitive cyclist and triathlete, and enjoys spending time outdoors with her family.
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