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THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright O The Orthopaedic and Sports Medicine Sections of the American Physical Therapy Associaton

Dysfunction of the Sacroiliac Joint and Its Treatment*

RICHARD L. DONTIGNY, BS, PTt
A very common but frequently overlooked cause of pain in the low back is a result of leaning forward without adequately supporting the anterior pelvis. This allows the innominates to rotate slightly downwards on the sacrum with fixation and an apparent increase in the length of the legs, which in turn irritates the sciatic nerve. This commonly occurs bilaterally but may occur on just one side. Flexion of the innominate(s) on the sacrum restores function to the sacroiliac joint, causes an apparent shortening of the legs and gives excellent relief of pain in the low back and sciatic pain.

Pain in the low back has been diagnosed and misdiagnosed, treated and mistreated for decades. The purpose of this article is to take a fresh look at pain in the low back, to describe the forces that precipitate the pain, to demonstrate a very simple method of relieving the pain and preventing recurrence, and to detail the conservative management of the problem. "In a Columbia-NYU study of 5,000 unselected back pain cases, muscle weakness or inelasticity was found to be the cause of pain in 81 percent. All other causes-including herniated intervertebral disk, tumor, arthritis, fracture, bone abnormality-made up only 19 percent."I6 It will not be within the scope of this article to discuss the management of disks, tumors, arthritis, or fractures, but rather the treatment of the other 81%, where physical therapists can be most effective. MECHANISM During normal standing posture the line of gravity passes slightly posterior to the center of ~~ When . the preponderance of the a ~ e t a b u l a .23 the weight of the upper trunk is carried on the posterior pelvis, the pelvis rotates downward posteriorly, around the acetabula, creating a rotational force in flexion (Fig. 1). A pelvic tilt is created automatically, with little or no assistance 59501.
* From the Northern Montana Hospital. P. 0. Box 1231.Havre, MT

t Chief Physical Therapist.

from the abdominal muscles. Contrary to some myths, man was beautifully designed to stand erect. Dysfunction occurs, not just during lifting, but when the patient leans forward or stands with lordotic posture. This causes the line of gravity to be displaced anterior to the center of the acetabula7.l5 creating a rotational force in extension around the acetabula (Fig. 2). If anterior pelvic support from the abdominal muscles is adequate, there is no problem. If, however, support from the abdominal muscles is not adequate, the anterior pelvis rotates downwards around the acetabulae. This anterior rotational force tends to rotate the innominate bones anteriorly on the sacrum, but because the sacrum is placed within the innominates and is wider anteriorly than posteriorly, the innominate bones tend to spread on the sacrum. On reaching the limit of their motion, they wedge and lock. By superimposing Figure 1 over Figure 2 (Fig. 3) we can see how the relationship of the acetabulum to the sacroiliac joint is changed. As the acetabulae move downwards and slightly posteriorly it causes an apparent lengthening of the legs. More common bilaterally, it frequently occurs unilaterally, causing pelvic obliquity and a high iliac crest on the same side when the patient n~~ the belief that is standing." L a r ~ o expressed the presence of a lumbar convexity on the side of the long leg depends on a sacroiliac lesion being present on that side. The apparent leg length difference, and thus

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proximately the same as or more than that of the acetabulum. Several authors have described anterior dysfunction of the sacroiliac joint, but some have referred to it in different terms such as "forward torsion sprain" or "sacroiliac slip".8, 18. 24. 26-28

EVALUATION AND CORRECTION

The passive straight leg raising test is most helpful in the evaluation of pain in the low back. Pain down the leg on passive straight leg raising, which is exacerbated by dorsiflexion of the foot, is indicative of sciatic nerve pain. Despite a study to the contrary by Danforth and W i l ~ o n , several '~ researchers have found a relationship between sciatic nerve pain and pain in the sacroiliac joint.l 8. 38. 40
Fig. 1. Sacroiliac region in normal posture. Arrows indicate normal rotation force in flexion. (Courtesy of The D.O.)

When the leg is raised, the pull of the hamstrings on the innominate bone causes a posterior torsion strain on the same side.27If this does not increase the pain in the back or if it eases the pain in the back, anterior dysfunction should be suspected. If passive straight leg raising causes pain or increases the pain on the same side, suspect a posterior or vertical complication. If passive straight leg raising causes pain on the contralateral side, suspect anterior dysfunction on the opposite side (rotating one innominate

Fig. 2. Region in lordotic posture. Reversal of rotation force around the acetabula with anterior shift of the line of gravity can be seen. (Courtesy of The D.O.)

the amount of excursion of the acetabulum, on the involved side can be measured from the posterior superior spine of the ilium to the medial malleolus and compared before and after correction or compared with the same measurement on the uninvolved side. Differences are usually from 3/8-5/8 in (1 -1.5 cm). Measurements from the anterior superior spine to the medial malleolus are not relevant in themselves because the excursion of the anterior superior spine is ap-

Fig. 3. Overlays of pelvis. Dotted line indicates position of the pelvis in lordotic posture and solid line that in normal posture. Movement of the acetabula can be seen. (Courtesy of The D.0 . )

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posteriorly, increases anterior dysfunction on the opposite sidez7). The most consistent sign that confirms the suspicion of anterior dysfunction is the manner in which the leg seems to shorten when the innominate is flexed on the sacrum. "If anterior dysfunction of the sacroiliac joint is suspected, an evaluation should be made to see if there is an apparent lengthening of the leg. The patient is placed supine on an examination table and his hips and knees are flexed toward his chest to flatten the lumbar spine, to minimize pelvic obliquity, to make sure the buttocks lie evenly and do not distort the patient, and to aid the patient to lie in a straight line. Then the hips and knees are extended to the table in the midline. The examiner stands at the foot of the table and grasps the patient's heels, one in each hand. The patient's hips are slightly flexed with the knees extended, and his heels are abducted from 12-1 6 in (30-40 cm). An upward thrust is made as if to thrust the heads of the femurs into the hip sockets. After this they are adducted and lowered to the table with an equal amount of mild manual traction on each, the medial malleoli being held together in the midline and care being taken to ensure that the patient is lying straight. This is similar to a method described by Beal,4 but the addition of some mild traction after the upward thrust seems to increase the apparent difference in leg length. If the leg on the painful side appears to be from 3/8-5/8 in (1-1.5 cm) longer at the malleoli or at the heels than the normal one, it may indicate anterior dysfunction of the sacroiliac joint with apparent leg lengthening on that side."" When evaluating the comparative leg length at the malleoli, any difference will be more obvious if you place a thumb beneath each medial malleolus when holding them together. "In the case of a suspected apparent lengthening of the right leg, confirmation is made by mobilization in the following manner: with the patient supine on the examining table, the therapist stands at the patient's right side and places his right hand between the patient's legs under the right ischial tuberosity and buttock. Then he places the heel of his left hand on the anteriorsuperior spine of the ilium with the fingers pointing laterally and rotates the right innominate bone strongly back and upward. Then he reexamines the patient's legs to see if the malleoli are even.""

An alternative method may also be used. The therapist stands facing the right side of the table and passively flexes the patient's right hip and knee along side of the chest toward the patient's axilla (Fig. 4), stretching slowly and firmly with the left elbow on the patient's right knee and grasping the patient's right ankle with the left hand. With the right hand, the therapist may either hold down the opposite leg, or grasp the patient's right ischial tuberosity and pull it upward, reinforcing the posterior rotational force while a colleague holds the left leg down on the examining table (Fig. 5). Then slowly lower the leg to the table and recheck at the malleoli to see if they are even and if the apparent leg lengthening is corrected. In addition, the patient may be instructed in correcting this himself as part of his postural exercise program. This can be done when supine, standing, or sitting as shown in Figure 6. If the legs appear to be even at the malleoli but bilateral anterior dysfunction of the sacroiliac joint is suspected, an attempt should be made to

Fig. 4. Method of mobilization to correct anterior dysfunction of the sacroiliac joint and reduce apparent lengthening of the leg. (Courtesy of The D.O.)

Fig. 5 . Alternate method of treatment, viewed from above. (Courtesy of The D.O.)

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A Complication of Anterior Dysfunction

If a patient has pain in the low back on the ipsilateral side during passive straight leg raising, when a posterior torsion strain is placed on the sacroiliac joint, it is not necessarily indicative of a posterior sprain or posterior dysfunction as has been proposed.27. 28 If ipsilateral pain is increased with flexion of the innominate on the sacrum, with the patient supine, grasp the leg above the ankle and put traction on the leg in the long axis. Pull firmly and then recheck the malleoli. The involved leg will now appear to be equal to or longer than the uninvolved leg. Now when the innominate is flexed on the sacrum there should be no pain and the leg will appear to shorten with correction. The direction of the maneuvers that relieve the pain and the resultant changes in apparent leg length give us important clues as to the nature of the dysfunction. Apparently the innominate rotates slightly anteriorly on the sacrum and then, perhaps after prolonged sitting, slips cephaladly complicating the original dysfunction. This, then, requires two separate maneuvers to correct-traction on the leg to correct the vertical slip and then flexion to correct the anterior dysfunction. Posterior torsion sprain or posterior dysfunction may exist by itself, but it is not common.

Fig. 6. Methods of self-correction. A, correction standing or supine, pull the knee into the ipsilateral axilla. Alternate several times. 6,with one foot on a table or bench, lean toward the knee stretching it into the axilla. Alternate. C, when sitting, pull one knee into the axilla and sit with it there for a few minutes. Alternate. Repeat these many times during the day and always make a correction just before bed that will relieve the strain on the involved ligaments for several hours.

rotate each innominate bone posteriorly on the sacrum. One innominate bone is rotated posteriorly, and then the patient is reexamined to see if the corresponding malleolus now appears to be higher than the uncorrected one, indicating correction into a shortened position. He then tips the uncorrected side posteriorly, and if a correction has been made, the malleoli will appear to be even. Frequently one side will be much more difficult to correct than the other, and for this reason an attempt at correction should be made on each side. When the less involved side is corrected, the difficulty in correcting the other side is lessened. Correction not only confirms the supposition of anterior dysfunction of the sacroiliac joint, but has the advantage of relieving the pain in the lower part of the back when apparent leg lengthening is present. One or two sessions of treatment may be enough to correct the condition if it results from recent trauma; but if the patient has suffered from recurrent backache and displays an obvious weakness of the anterior pelvic support, the malleoli must be checked at each treatment session and the apparent lengthening corrected as necessary to relieve the strain on the involved ligaments and allow them to recover." It is frequently necessary to flex each innominate on the sacrum alternately, two or three times, until no more apparent shortening takes place.

MEASUREMENTS
Measuring the leg length in the conventional manner from beneath the anterior-superior spine of the ilium to below the medial malleolus probably will not demonstrate any appreciable difference between the side with the apparent lengthening and the normal side. Menne1Iz7suggested that while the patient is standing both legs be measured from the anterior-superior iliac spines to the floor and from the posterior-superior iliac spines to the floor. This will make apparent any rotation of the pelvis on one side or the other. The apparent increase in leg length that occurs with the anterior dysfunction of the sacroiliac joint may make the crest of the ilium on the involved side higher than the crest on the uninvolved side even though the anterior-superior spine of the ilium on the involved side may be even with or slightly lower than the other. When this occurs, the posterior-superior spine will measure slightly higher on the involved side.''

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If each measurement on one side is longer than each measurement on the other side, an actual difference in leg length is probable. In the presence of even moderate pain in the lower part of the back, it is not possible to determine a difference in actual leg length without first mobilizing the innominate bone upward and posteriorly to see if apparent leg lengthening is present. Bailey and Beckwith3 stated that "often a difference of a centimeter or more in the heights of crests will be wiped out following the correction of a pelvic lesion." The posterior-superior spines also will measure lower after mobilization treatment than before. With the patient prone, careful measurements from the posterior-superior spines to the medial malleoli before and after mobilization will demonstrate shortening of from in (1 -1 .5cm)." In order to determine whether the high crest is caused by a difference in leg length causing a pelvic obliquity or by pelvic obliquity causing an apparent difference in leg length, the level of the iliac crests should be checked first with the patient standing and then with the patient sitting on a firm surface. If one crest is still high with the patient sitting, then it is probable that pelvic obliquity caused the apparent discrepancy in leg length. Crest height during sitting frequently is equalized after proper corrective manipulation."

Fig. 7 . Tracings of roentgenograms. Doffed line represents pelvis before correction of anterior dysfunction of the sacroiliac joint on the left. Solid line shows pelvis after correction. Tracings were overlaid to demonstrate movement that occurred on correction. (Courtesy of The D.O.)

DEMONSTRATIONS
Roentgenograms were taken before and after mobilization of an apparent leg lengthening of the left lower extremity of a 21-year-old man. The patient was positigned supine on the roentgen ray table and both knees were flexed to his chest to flatten the lumbar spine, minimize pelvic obliquity, and assure the symmetry of the gluteal muscles. The patient's feet were then extended to a tape mark on the table while the hips and knees were left comfortably flexed, and a roentgenogram was made. Then the left innominate bone was moved posteriorly on the sacrum and a second roentgenogram was taken with the patient in the same position. Tracings of the roentgenograms (Fig. 7) demonstrate the movement that took place. The pelvis was flattened. The sacral plateau was flattened, indicating flattening of the lumbosacral angle. Slight reduction of the width of the pelvis suggests that the innominate bones may have been wedged apart by the sacrum prior to mobilization. The acetab-

ulum on the left was higher than the one on the right without a corresponding increase in height of the iliac crest. This suggests rotary movement rather than a lateral tilt. The right deviation of the pubic symphysis moved medially with some lateral movement of the right ilium on the sacrum. Finally, there was a definite movement downward of the left ilium on the sacrum, seen at the posterior-superior spine and greater sciatic notch in relation to the first sacral foramen.I8 Roentgenograms were made of a second young man with a suspected bilateral anterior dysfunction of the sacroiliac joints, before and after flexing each innominate on the sacrum. These were done with the patient standing, weight evenly distributed on both feet and the knees fully extended. A roentgenogram (Fig. 8) was made before correction, a second (Fig. 9) after flexion of the right innominate on the sacrum, and a third (Fig. 10) after flexion of the left innominate on the sacrum. Figure 9 shows a slight flattening of the sacral plateau. Figure 1 0 shows a definite flattening of the sacral plateau with a resultant, widening of the L5-S1 interspace. It also shows a definite movement downward of the posterior superior spines in relationship to the first sacral foramina.

ASSOCIATED CONDITIONS Referred Pain

Pain most commonly found with anterior dysfunction is "tenderness over the symphysis

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Fig. 8. Roentgenogram of a suspected bilateral anterior dysfunction before correction.

pubis on the side affected, tenderness over the iliosacral articulation on the side affected, and tenderness along the crest of the ilium where the abdominal muscles are attached.26 Norman and May32found that "a sacroiliac lesion produces pain over the gluteal region, the posterior thigh, the posterolateral calf and the lateral border of the foot." Occasionally there will be associated pain in the abdomen at Baer's sacroiliac point, which has been described as being 2 inches from the umbilicus on a line drawn from the umbilicus to .the anterior-superior spine.27 Torsion strain on the sacroiliac joint can modify tenderness at this point. Norman33also found abdominal pain associated with sacroiliac dysfunction. Wilson42 called attention to the fact that "unusual radiation of pain from the lower three lumbar vertebral joints has led to the unnecessary removal of pelvic organs in the female and to coccygectomy."

Although sciatic nerve pain is frequently associated with anterior dysfunction of the sacroiliac joint it is probably not a referred pain. Danforth and Wilsoni4 determined that the sacroiliac joint did not act directly to cause sciatic nerve pain because "there is no canal nor semblance of a canal which holds the nerves against the joint." It seems reasonable that the nerve trunk could be irritated directly by the undue stretching of the sciatic nerve associated with the apparent lengthening of the leg found with anterior joint d y s f u n ~ t i o n . 'In ~ a person with an anterior dysfunction the nerve is stretched even more with every step during normal gait; when flexion of the hip is followed by extension of the knee and dorsiflexion of the ankle, which is merely a vertical variation of Lasegue's test. Cailliet6explains that "stretching the nerve stretches the dural sheath of the nerve and thereby impairs its blood supply, the ischemia of the nerve causing the pain."

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Pain on Sitting
If wedging at the sacroiliac joints has already slightly spread the innominate bones, any pressure that might increase the spreading and the resultant ligamentous stretch probably would be p a i n f ~ l . 'Grant2' ~ stated that "In the standing posture, the acetabula and the sidewalls of the pelvis tend to be forced together, but the pubic bones, acting as struts, prevent this from happening. In the sitting posture the ischial tuberosities tend to be forced apart." Note in Figure 3 that when the innominates are rotated, the ischial tuberosities are behind their normal position. Weight-bearing on them during sitting increases the anterior rotational strain on the ligaments, tending to spread the innominates and increasing the distance between the posterior superior spines. Menne1I2' found an approximation of the posterior superior spines on sitting from prone, while Colachisi0

found a separation. Actually, they can go either way, depending on whether the patient is sitting with the pelvis slightly extended with anterior joint torsion or with the pelvis slightly flexed with posterior joint torsion. There is little or no pain on sitting if the patient will sit 4 or 5 in (10-1 2 cm) from the back of the chair and then slump, sitting on the back of the pelvis rather than on the bottom of the pelvis. Nachemson's studies3' have found an increase in intradiscal pressure on sitting but the author believes that it is probably not related to pain produced by the sacroiliac joint on sitting, because while sitting in some degree of extension may be painful, sitting in flexion is usually not, especially after proper mobilization.

Pain on Increase of lntraabdominal Pressure

Anything such as coughing or sneezing or constipation which increases intraabdominal

Fig. 9. Bilateral anterior dysfunction after flexion of the right innominate on the sacrum.

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Fig. 10. Bilateral anterior dysfunction after flexion of the left innominate on the sacrum. Note widening of L5-S1 interspace and movement downward of the posterior superior spines in relationship to the first sacral foramina.

pressure has a tendency to spread the innominates and may precipitate pain or increase existing pain. The increase in intradiscal pressure that accompanies an increase in intraabdominal pressure may not be associated with the increase in pain because if you stabilize the pelvis by manually compressing the ilia you can usually sneeze or cough in relative comfort and this maneuver is not likely to affect intradiscal pressure one way or another.

Changes in Gait
Charles Ducroquet was reported by his sons to have remarked that certain painful reactions of the sacroiliac joints lead to a shortening of the step. His sons added this comment: "The pain of torsion of the sacrum on the iliac wing, in reality, limits the pelvis ~ t e p . " ' The ~ length of the

step may also be shortened to protect a painful sciatic nerve. Climbing stairs is frequently painful. Weakness in the anterior pelvic support allows the innominate to rotate downward on the sacrum as the hip flexors, pulling from the iliac fossa, raise the weight of the leg upward during swing phase. Chronic weakness in the anterior pelvic support, especially accompanying obesity makes the hip flexors less efficient by approximating the origin to the insertion. The patients will frequently walk with their hips in external rotation using their hip adductors to assist with flexion. This can cause a valgus deformity at the knees.

Pain During Pregnancy

Anterior dysfunction is particularly common during pregnancy as weight on the anterior pelvis causes an anterior torsion strain on the sa-

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croiliac joints. Relief can be obtained by frequent flexion of the knee to the axilla and by instructing the patient to lean slightly backwards from the hips when standing so that most of the trunk weight is on the posterior pelvis.

Instability Before the Menstrual Cycle

Women are particularly susceptible to anterior dysfunction about a week or 10 days before the menstrual cycle. The presence of relaxin in the body at that time precipitates a hormonal ligamentous laxity that renders the pelvic ligaments more prone to minor injury. The relaxin is reabsorbed during the menstrual cycle and, if the innominate is kept in its normal position on the sacrum at this time, the pelvic ligaments regain their normal stability. It has been our observation that if the dysfunction is not corrected, the instability may continue until the next menstrual cycle.

MANAGEMENT
Evaluation and mobilization must be done before the application of any modalities. It is essential that the patient and the therapist be acutely aware of any movement which initiates or eliminates, aggravates or alleviates pain. You do not mobilize into pain. Everything must be done within the limits of pain.

not anesthetic. Cold, while anesthetic, is not particularly analgesic. Whether you use wet or dry heat is unimportant. While wet heat is more penetrating than dry heat at the same temperature, dry heat can be tolerated at higher temperatures. At the hiqhest tolerated temperatures, heat penetration is about equal.' When cold is used, there is little point in applying it before the electric stimulation and massage as this will warm the area which has been cooled. The effects of the cold will last longer when applied after the other modalities. The cold should be applied over a dry towel or a warm damp towel to avoid an initial shock to the patient. Relaxation is enhanced if heat is applied to another part of the body while the cold packs are in place to maintain core temperat~re.~.31 The use of continuous heat prior to mobilization is contraindicated. The local increase in circulation from the prolonged application of heat causes edema which frequently prevents mobilization correction.
1 7 3

Traction
Pelvic traction does not seem to be helpful in the treatment of anterior dysfunction of the sacroiliac joint. However, wrapping the pelvic traction belt snugly around the pelvis does seem to help prevent recurrence by preventing the innominate bones from spreading and thus limiting the amount of wedging possible. The overlapping flaps from a Scultetus binder with a tail stitched to it posteriorly make an excellent pelvic traction belt, which is comfortable and completely adjustable." Leg traction applied to a patient with apparent lengthening of the leg serves only to increase the deformity, pulling on the longer involved side when shortening is necessary." Intermittent traction is effective in separating the vertebrae which may be necessary to relieve pressure on a disc.g In the presence of pain from a facet syndrome intermittent traction may separate the vertebrae enough to relieve the binding and allow normal realignment.

Rest in Bed
During the acute phase, rest in bed is very important. When lying on the side, place a pillow between the knees. When lying supine, a pillow placed under the low edge of the buttocks is extremely helpful. This tends to keep a slight pressure in posterior rotation and frequently relieves all pain so that the patient can rest much better. Making the patient comfortable frequently makes additional medication unnecessary.

Modalities
For the relief of chronic pain, we find that mobilization followed by heat, electric stimulation (with or without ultrasound), and massage is effective. The currents used for transcutaneous electrical nerve stimulation5.25. 35. 37 are particularly helpful in relieving back pain and their effects seem to last much longer if used after mobilization correction. If the pain is acute, we follow mobilization with electric stimulation, massage, and an ice pack. Heat, while analgesic, is

Exercise
Proper exercise is absolutely essential to relieve pain and to prevent recurrence of joint dysfunction. The patient must be instructed thoroughly in what to do, how to do it, and why it must be done. The 1st day, demonstrate to the

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patient what must be done. The 2nd day, have the patient demonstrate what is being done so corrections may be made if necessary. Correction of anterior dysfunction by flexion of the innominate on the sacrum is done by having the patient flex his knee to the axilla as shown in Figure 6. This must be done two or three times on each side, alternating sides. This should be done several times a day and especially upon going to bed to relieve the dysfunction and allow the ligaments several hours during the night to recover. This minimizes getting up with a stiff sore back in the morning. Flexion of the knee to the chest flexes the pelvis and the spine and does not provide adequate correction. Flexion of the knee to the axilla flexes the innominate on the spine. In order to prevent recurrence of back pain, the patient must learn to use his abdominal muscles constantly to support the anterior pelvis. It is especially important to hold the abdominal muscles in tightly and to pinch the buttocks tightly together to stabilize the pelvis when leaning forward, whether to shave, make a bed, work over a counter, or to lift something. The abdominal muscles should be strengthened to provide sufficient pelvic support by doing a partial sit-up, with the hips and knees bent. Leg-raising exercises should never be used as an abdominal strengthening exercise. Aside from the fact that the abdominal muscles don't raise the legs, in the absence of a strong stabilizing force from the abdominals on the anterior pelvis, the pull of the iliacus from the iliac fossa causes a strong anterior rotational force of the innominate bones on the sacrum. All leg raising exercises should be ~ontraindicated.~ The downward inclination of the pelvis and increased difficulty in doing a pelvic tilt which occurs with anterior joint dysfunction gives the impression of tightness in the hip flexors. Evaluation of hip flexor tightness should be made following correction. lfstretching of the hip flexors are necessary, it should be done with care as it puts an anterior rotation strain on the sacroiliac joint, which may precipitate or increase an anterior dysfunction of the sacroiliac joint.

program. It should be put on after treatment when the joint dysfunction has been corrected. A good sacroiliac support or even a simple trouser belt worn just below the anterior-superior iliac spines will serve to stabilize the pelvis, although a good lumbosacral support of fabric with at least two paravertebral metal stays and adjustable side lacing will be more effective. This provides stability in both pelvic and lumbar flexion. To be most effective, the support must be put on properly. The patient should lie supine on the opened support and flex his knees to his axillae as described. This also minimizes the sacral angle, flattens the lumbar lordosis, and lessens pelvic obliquity. He then places his feet flat on the table, with the hips and knees flexed, and the support is fastened and adjusted snugly, especially around the pelvis, where it tends to relieve the strain on the pelvic ligaments by preventing spreading and locking. In this position the support will help to maintain the postural corrections that have been made and to prevent recurrence of the anterior dysfunction. If the support is put on when dysfunction is not corrected, it not only will fail to correct the joint dysfunction, but may increase pain by increasing pressures on the pelvic joints in that position."

Heel Lifts
A heel lift may be prescribed for a patient with one leg shorter than the other, but only after careful measurements indicate an actual bony discrepancy. A heel lift should not be considered if apparent differences in leg length can be corrected quickly by a painless mobilization maneuver. Heel lift therapy is frequently used to correct a high iliac crest in patients with idiopathic scoliosis. These patients should also be evaluated for anterior dysfunction of the sacroiliac joint before recommending a heel lift.

Transcutaneous Nerve Stimulators

While electric stimulation is extremely helpful in the acute phase, after the patient has been established on an effective home program, it is seldom necessary. It is occasionally helpful in cases of obesity and chronic joint instability.

Supports
Occasionally it may be necessary to use a support, especially with long-standing obesity, excessive abdominal weakness, or chronic joint instability. Its use should supplement but not replace a good prophylactic postural training

FUNCTION
The sacroiliacjoint is a strong joint structurally and in recent years it has been regarded as a "misconception" that "the sacroiliac joint was

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susceptible to strain and subluxation from trivial Gray's Anatomy2' states that the function of the sacroiliac joints is to lessen concussion in rapid changes of distribution of body weight in each of two directions. In doing so it undergoes some rotation through a transverse axis. One component of the force is expended in driving the sacrum downward and backward and is resisted by the wedge shape of the sacrum and the sacroiliac and iliolumbar ligaments. The second component of force produces a rotatory movement by which the superior end of the sacral articulation is tilted down and the inferior part up and is resisted by the wedge form and the sacroiliac, sacrotuberous, and sacrospinous ligaments. The joint acts as a shock absorber. If an outside force creates a minor displacement of the articular surfaces of the sacroiliac joint, the displacement is quickly corrected by the strong pull of the surrounding ligaments aided by the wedge shape of the sacrum. O'D~noghue stated ~ ~ that the sacrum is the keystone of the pelvic arch. Grant2' described the rotary movement of the sacrum and stated: "The articular surfaces of the sacrum are farther apart in front than behind: so, the sacrum behaves not as a keystone, but as the reverse of a keystone, and tends therefore to sink forwards into the pelvis. As it does so, the posterior ligaments become taut and draw the ilia closer together with the result that the interlocking ridge and furrow engage more closely. Here is an automatic locking device." This would seem to bear out the early observations of Cunningham,12 of which Dwight said that "As the sacrum narrows towards its dorsal surface, and is really suspended from the iliac bones by the posterior sacroiliac ligaments, it cannot be considered as the keystone of an arch." In its normal functioning state, the sacroiliac joint is a nonweight bearing joint. S~hunke noted ~ ~ that supernumerary sacroiliac facets are common and stated that "only slight motion would be required to dislocate them or other slight irregularities upon the articular surfaces. Tension of the interosseous ligaments would tend to keep such prominences dislocated and resist the separation necessary for their relocation, though they might be made to 'snap' back into position by more or less strenuous mobilization." Trotter4' found that accessory sacroiliac articulations occur in man in varying percentages. "It would seem that the sacrum is well pro-

tected from sinking into the pelvis and the ilia from rotating posteriorly on the sacrum. Unfortunately, the relatively thin sheath of anterior sacroiliac ligaments does not offer the same protection from movement and injury in the opposite direction. Anterior rotation of the innominate bones on the sacrum not only tends to loosen the fibers of the strong posterior sacroiliac ligaments, but spreads the ilia on the sacrum causing them to wedge or bind. Fixation of the sacroiliac joint prevents function, and forces previously expended in the joint are transmitted to the intervertebral disk. This may be a significant factor in herniation of the disk."l8 On heel strike, the force created travels up the leg and is absorbed in the sacroiliac joint as the innominate is caused to rotate slightly posteriorly on the sacrum, stretching the heavy posterior sacroiliac ligaments which in turn cause the innominate to return to its normal resting position. If the function of the sacroiliac joint is blocked, then this posterior force, instead of being absorbed, causes the entire pelvic ring to be torqued around the L5-S1 disk. It seems highly probable that this is the cause of the torsion changes that occur in the disk before herniation. Pain in the low back is also a frequent accompanying affliction of patients with hip disease. The lateral thigh muscles that originate from the iliac crest posterior to the line of gravity and lie posterior to the greater trochanter are in a relatively shortened position during normal standing posture. In the lordotic posture and during anterior dysfunction of the sacroiliac joint the innominate rotates around the acetabula so that the origin of those muscles on the iliac crest moves anteriorly and the greater trochanter moves posteriorly and the muscles which laid posterior to the trochanter now lie over the top of the trochanter stretching those involved muscles. As those muscles are stretched and functioning from an unnatural position they also serve to pull the head of the femur more tightly into the acetabulum disposing it to increased wear from the increased pressure. This is probably exacerbated by an increase in apparent leg length and increased trauma to the head of the femur because of the jarring effect created on heel strike with the nonfunctioning sacroiliac joint. Individual anatomical variations and variations in gait are also contributing factors.

COMMENTS
Before the work of Danforth and Wilson14 in 1925, sacroiliac dysfunction was frequently

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Vol. 1 , No. 1

found and associated with sciatic pain, but since no anatomical relationship was found, the diagnosis was assumed incorrect. When Mixter and Barr2' described the herniated intervertebral disk in 1934 it was then assumed that sciatic pain was a result of a herniated disk. Since about 60-70% of people with pain in the low back have some degree of sciatic nerve irritation, but only about 5% of patients with pain in the low back undergo surgery for herniated disk, this relationship is unlikely. The relationship between sacroiliac dysfunction and sciatic pain exists, but is biomechanical in nature rather than strictly anatomical. Of all cases with pain in the low back, referred to this department, just over 80% have anterior dysfunction of the sacroiliac joint and of those, about 55% were affected bilaterally. Frequently radiographic evidence does not correspond to clinical evidence. Cyriax13 commented: "Everytime a patient is labelled 'cervical spondylosis,' 'lumbar arthritis' or 'degenerate disc' it is highly probable that an error in emphasis has been made. Although this is what the roentgenogram shows, a few months from now when the patient has no symptoms he will still have his osteophytes or his narrowed space." Unfortunately, the traditional approach to mobilization of the sacroiliac joint has been an attempt to correct a high iliac crest by extending the innominate on the sacrum. This is usually done with the patient side-lying and with the operator behind the patient pulling backward on the shoulder and thrusting the innominate forward and downward on the sacrum. This is done in the mistaken belief that a high crest is caused by an upward dysfunction of the joint when, actually, the high crest is caused by anterior dysfunction and concurrent apparent lengthening of the leg. This maneuver could serve to open the joint slightly at which time the taut sacroiliac ligaments would rebound the innominate into its proper position, usually with a disconcerting thud. If this method of mobilization in the wrong direction is continued for any period of time, one of two things will happen: the joint will be jammed much more tightly, or it will become unstable requiring frequent adjustment usually at great cost and inconvenience to the patient. If at all possible, the shock absorber function of the sacroiliac joint should be maintained, however some researcher^"^^' have reported excellent relief of pain in the unstable joint following

surgical fusion. If fusion is considered it would seem that the joint should be fused in a corrected position. If it is not corrected before fusion, a torsion strain is built into the pubic symphysis and further instability is likely to occur in that area." There is presently much too great a tendency to become method oriented in the treatment approach. Conservative therapists tend to stay with heat and massage not wanting to do more for fear of hurting the patient, but perhaps not doing enough to help the patient either. The acupuncturists and those practicing shiatsu may not be using mobilization, or cold, or heat and massage when they are indicated. The manual therapists should similarly include any appropriate modality or procedure, even though it may extend the treatment time somewhat. Everyone should question the sequence of modalities and whether they are appropriate. The key is proper evaluation of the problem and then becoming problem oriented, adapting the methods to the problem rather than the problem to the method.

SUMMARY
Pain in the low back is commonly precipitated when an individual leans forward to perform some task and fails to support his anterior pelvis with his abdominal muscles. The resultant anterior rotation of the innominate(.$ on the sacrum may result in fixation, acute pain and an apparent lengthening of the leg(s). It is more common bilaterally, but frequently occurs on just one side. The apparent lengthening of the leg(@ is a result of the alteration of relationship between the sacroiliac joints and the acetabulae. The lengthening of the leg(s) results in a lengthening of the sciatic nerve which frequently causes a sciatic neuritis. Flexion of the innominate(s) on the sacrum by flexion of the knee to the ipsilateral axilla releases the fixation, relieves the pain, appears to shorten the leg and takes the stretch off of the sciatic nerve. Recurrence is prevented by supporting the anterior pelvis with the abdominal muscles especially when leaning forward. The corrective maneuver is safe as it causes minimal flexion. extension, or rotation of the spine. Occasionally, after the innominate has rotated anteriorly on the sacrum, it may also jam slightly vertically, complicating the original anterior dysfunction. This requires two maneuvers to correct;

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manual traction on the leg in the long axis to correct the vertical complication and then flexion of the innominate on the sacrum to correct the anterior dysfunction. Relief is usually immediate.
The author thanks Dr. Clark Grimm and the Radiology Department of Northern Montana Hospital who provided the roentgenograms and to the American Osteopathic Association and The D.O. for their kind permission to reprint illustrations and quotations from an original article.

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