The sacroiliac (SI) joint is the largest axial joint in the body, with an average surface area of 17.

5 cm2 . There is wide variability in the adult SI joint, encompassing size, shape, and surface contour. Large disparities may even exist within the same individual. The SI joint is most often characterized as a large, auricular-shaped, diarthrodial synovial joint. In reality, only the anterior third of the interface between the sacrum and ilium is a true synovial joint; the rest of the junction is comprised of an intricate set of ligamentous connections. The sacroiliac joints are two paired "kidney bean" or L-shaped joints having a small amount of movement that are formed between the articular surfaces of the sacrum and the ilium bones.The two sacroiliac joints move together as a single unit. The SIJ's stability is maintained mainly through a combination of only some bony structure and very strong intrinsic and extrinsic ligaments. As we age the characteristics of the sacroiliac joint change. The joint's surfaces are flat or planar in early life but as we start walking, the sacroiliac joint surfaces develop distinct angular orientations.

Ligaments
Ventral Sacroiliac Ligament Assists the symphysis pubis in resisting separation or horizontal movement of the innominate bones at the SI joint. Palpated at Baer's SI point (Point on a line from the umbilicus to the anterior superior iliac spine (ASIS) 5 cm from umbilicus). Stressed using transverse anterior/posterior compression pain provocation test. Weakest among the sacro iliac ligaments. Long Dorsal Sacroiliac Ligament During incremental loading of the sacrum, it becomes tense during counternutation (base of the sacrum moves backward) and slackens with nutation (opposite movement of sacrum) [6]. Palpated in the area directly caudal to the posterior superior iliac spine (PSIS). Interosseous Sacroiliac Ligament

Largest syndesmosis in the body and functions as the major bond between the bones filling the irregular space posterior-superior to the joint. Resist anterior and inferior movement of the sacrum. Primary barrier to direct palpation of SIJ. Sacrotuberous Ligament Plays significant role in stabilizing against nutation of the sacrum, and conteracting against the dorsal and cranial migration of the sacral apex during weight bearing. Tension increaseswith contraction of Gluteus maximus. Sacrospinous Ligament Along with sacrotuberous ligament, it opposes forward tilting of the sacrum on the hip bone during weight bearing of the trunk and vertebral column.

The motions of the sacroiliac joint

Anterior innominate tilt of both innominate bones on the sacrum (where the left and right move as a unit) Posterior innominate tilt of both innominate bones on the sacrum (where the left and right move together as a unit) Anterior innominate tilt of one innominate bone while the opposite innominate bone tilts posteriorly on the sacrum (antagonistic innominate tilt) which occurs during gait Sacral flexion (or nutation) Motions of the sacrum occur simultaneous with motion of the ilium so you must be careful in the description of these as isolated motions. Sacral extension (or counter-nutation).

Sacroiliac Joint Dysfunction

Sacroiliac Joint Dysfunction or SI Joint Dysfunction is a condition in which the joint is locked, partially dislocated or "subluxated" in a non-anatomically correct position due to hypermobility (too much movement) or hypomobility (too little movement) within the joint. Sacroiliac joint dysfunction is commonly characterized by low back and gluteal pain and may be accompanied with referred groin, hip, and sciatic leg pain . The condition can affect one sacroiliac joint (left or right), or both joints. The degree of pain and disability due to the condition can vary widely, from an occasional discomfort that limits certain activities to severely debilitating and a constant source of pain.

Outflare
When the lumbar spine is extended and the sacrum nutates we have a bilateral outflare. Or when a single innominate is posteriorly rotated, the ASIS on that side may move away from the mid-line, (a unilateral outflare). This outflare (or external rotation) of the innominate means that the position of the acetabulum has changed, and the hip joint will be also externally rotated. However, the hip joint may compensate with internal rotation. It is also possible that the innominate can be pulled to an outflare position by muscular and fascial forces, without necessarily rotating the innominate posteriorly. Remember that living bone is pliable and plastic. Some of the most common culprits here are the tensor fascia lata, the iliotibial band, and gluteus minimus.

Inflare
When the spine is flexed, and the sacrum counter-nutates and the ASISs move toward each other, we have a bilateral inflare. A unilateral inflare can occur when a single innominate is anteriorly rotated (the ASIS on that side moves toward the mid-line). However, the anterior portion of the innominate can be pulled toward the mid-line without the presence of anterior

rotation. As with outflares, it is usually muscular and connective tissue force that causes the inflare, via the iliacus, internal obliques, sartorius and a contracturing inguinal ligament.

Upslip (Superior Shear)

If the ASIS, PSIS and the ischial tuberosity on the same innominate are all higher than the contralateral innominate, then we have what is called an upslip of the innominate on the sacrum. This is the result of a shearing of S.I. joints and the pubic symphysis. Another palpable observation is that the greater trochanter on the side of the upslip should be higher than its opposite. (If the femur and tibia are truly equal in length, the leg on the side of the upslip will likely look shorter.) There would be a shearing taking place at the pubic symphysis. Therefore, if palpated, the pubic bone would also be found to be higher on the side with the upslip.

DOWNSLIP
It follows that there is the possibility of a downslip, or inferior shear, the opposite of an upslip. A downslip would usually immediately self-correct upon weight-bearing. However, even if corrected by weight-bearing, the sacral joints and the pubic symphysis may not all necessarily correct automatically. One or more joints may be held misaligned due to a persistent muscle imbalance caused by the original shearing. If the downslip does not correct on its own, it may imply a dislocation of the S.I. joints and pubic symphysis, and would present as severely painful.

Bilateral Anterior Rotation Of Innominates (Anteriorly Tilted Pelvis)

This is when both ASISs are lower than the PSISs (when compared bilaterally) by an angle of more than 15 from level when viewed from the side. Such mal-positioning of the pelvis is usually dueto muscle imbalance, especially short hip flexors. This will result in an increased lumbar lordosis(hyperlordosis) which will put increased strain on the intervertebral joints (discs, vertebral bodies, facet joints, ligaments, etc.). The anterior tilt also moves the lumbar spine out of neutral position: the joints of the spine and the S.I. joints will behave as if the person is bent backward into extension at the low back. This predisposes all these joints to more readily become injured and impaired. With respect to the sacrum, this anterior tilt causes it to go into

nutation and resist returning to neutral. Therefore, during walking the S.I. joints will lose some of their mobility.

Bilateral Posterior Rotation of Innominates (Posteriorly Tilted Pelvis)

Both ASISs are level with, or even higher than, the PSISs when observed from a lateral angle. This causes a decrease in the lumbar lordosis or flat back. The sacrum is pulled into a counternutated position. This positioning of the structure of the lumbar spine and sacrum will impact on the function of the associated joints, affecting the health of the intervertebral discs and making the S.I. joints prone to impaired motion. One of the most consequential effects of this is loss of the natural spring that belongs to the regularly curved lumbar spine: movements coming up from the ground are now more jarring through the spine. Again, note that one innominate may be more posteriorly rotated than the other.