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demonstrate a modified muscle-energy assessment and correction routine for a painful left unilateral extended sacrum.
SI Biomechanics
Since most SI joints only move about 2 to 4 millimeters during weight bearing and forward bending, they are described as a gliding-type joint. This motion is quite different from the hingetype articulation at the knee or the ball-and-socket motion of the hip. Considered a viscoelastic joint, the SIs major movement comes from ligamentous stretching. Therefore, its primary function within the pelvic girdle is to provide shock absorption for the spine by stretching in various directions. When sacroiliac joints work in perfect harmony with the third bony articulation of the pelvis (symphysis pubis), a marvelous self-locking mechanism develops that helps us walk. Aided by power generated by the hip abductors (gluteus medius/ minimus, TFL and piriformis), the pelvic joints brace the weight-bearing side during gait. This locking system, termed force closure, allows smooth transference of body mass from one leg to the other (Fig. 3). Although no muscles directly bind down the three pelvic joints, when working synchronously with the SI ligaments they provide the pelvis the great adapter with a remarkable antigravity springing system that can absorb both ascending and descending forces (Fig. 4). During the aging process, there is an increase in the grooves on the opposing surfaces of the sacrum and ilium, which reduces available motion of the SI joint. This is a perfect example of the bodys innate wisdom attempting to sacrifice complexity of motion for stability. An interesting note is that the age with highest incidence of disabling back pain (25-45 years) is the same age at which the greatest amount of motion is available in the sacroiliac joints. Its not uncommon for an SI joint to become stiff and permanently lock as we age. This may be a good reason for massage therapists to begin incorporating specialized soft-tissue mobilization techniques on a regular basis, to maintain joint-play and prevent agonizing arthrosis and arthritis from developing. Due to the small amount of sacroiliac movement and the joint's inherent biomechanical complexity, proper assessment can be tricky. Frequently, muscle imbalance patterns develop as tissues become strained from overuse, underuse or abuse. In the early stages of a typical SI pain episode, protective muscle spasm arises as the sacrum gets stuck side-bent and rotated between the ilia, usually from a forward-bending and twisting incident (Fig. 5). Sustained isometric contraction produces muscle toxicity and weakness causing increased SI ligament loading and overstretching. As the articulating joint surfaces become jarred loose, ligament microtearing creates an inflammatory response. Sensitive
chemoreceptors bombard the spinal cord and brain with noxious stimuli, causing the brain to layer the area with protective muscle guarding. This is the beginning of a therapeutically challenging pain/spasm/pain cycle that often is hard to break. Its possible, however, to eliminate pain emanating from hypermobile joints by restoring proper pelvic alignment, frictioning the loose ligaments and addressing core strengthening exercises.
recurring unilateral hamstring pulls always should be evaluated for hip capsule restrictions that might be causing iliopsoas facilitation and glute max inhibition. The most common cause of persistent hamstring injuries results from an altered firing order pattern, whereby a weak gluteus maximus fires late during hip extension, forcing the hamstrings to do all the work. Since motionrestricted joints can reflexively weaken associated muscles, its a good idea to mobilize all capsular restrictions and lengthen tight postural muscles before attempting to strengthen muscle groups perceived as weak. Once optimal hip range of motion and iliosacral alignment are restored, sacroiliac problems often spontaneously correct themselves but not always. If low back, buttock or leg pain persists, the therapist must be equipped with proper assessment and treatment tools to effectively deal with SI joint syndrome.
References 1. Parisien RC, Ball PA. William Jason Mixter (1880-1958). Ushering in the "dynasty of the disc." Spine Nov. 1998;23(21):2363-6. 2. Mitchell F. An Evaluation and Treatment Manual of Osteopathic Muscle Energy Techniques. Institute for Continuing Education in Osteopathic Principles, 1979. 3. Janda V. Treatment of chronic back pain. Journal of Manual Medicine 1992;6:166-8. 4. Warmerdam A. "Arthrokinetic Therapy: Improving Muscle Performance Through Joint Mobilization." Class notes from International Federation of Orthopaedic Manipulative Therapists, Vail, Colo., 1992.