Sacroilliac Innominate Rotation and Associated Lumbar Dysfunctions
Sacroiliac (SI) joint pain and innominate rotation is often driven by lumbar spine mechanical dysfucntion. Whether that dysfunction is driven by a herniated disc, a weight bearing instability (please see future posts), or just motor control/movement impairment syndrome, the innominate rotation will have an associated lumbar impairment.
I’m open to a chicken and egg discussion, but this post is mostly about some observations I have made that are associated with SI and lumbar pain.
Rotation fixation or mobile rotation of an innominant should first be confirmed using weight bearing and non-weight bearing kinetic tests to confirm that you are looking at a true fixation. SI provocation tests should be performed to rule out an inflammatory disorder at the SI joint which is usually something to be quite concerned about. Once the pain is determined to be from mechanical tissue strain and any contraindications to manual therapy are ruled out, mobilize it. You can do this however you want. The more I work with the SI, the more I realize that you could just wink at the thing the right way and it will move, but once the motion returns, the drivers of the issue remains.
The patterns for innominate rotation are as follows:
If the left innominate is fixed or held unfixed towards posterior rotation, then you will see a right on right sacral torsion with increased femoral medial rotation on the right and low lumbar flexion loss (usually L5-S1) on the right driving the sacral torsion. Check out my post on the lumbar cascade to read more about what you can use to assess this dysfunction further. I find that once the flexion loss is treated, then lumbar and pelvic rotation will be restored to neutral.
Anterior rotation of the right innominate (fixed or unfixed) will be associated with a low lumbar extension loss on the left. Iniatially, you will observe increased medial rotation of the left femur and once the SI fixation is resolved, this will change to increased medial rotation of the right femur. At that point, I assess the sacral torsion to lead me to the left on right sacral torsion. Once the extension loss is resolved, the pelvis and spine return to a neutral position. This is without the influence of dysfunction in the thoracolumbar junction.
I always look at L5-S1 first as a source and then move up through lumbar segments. Thoracolumbar junction rotational fixation can drive the impairments described above. A loss of right rotation at the TL junction will result in increased medial rotation of the femur on the right and can be investigated using the hip scan described in the lumbar cascade post.
Again these are just observations, but I’ve been successfully using my hip scan to identify, treat and reassess Si dysfunction. You can also teach the patient how to use a Fabers Test to self-assess, treat and then reassess his own alignment faults.
Now, obviously, we are not just and set of hinges and bolts. There is the dynamic component to the architecture to be concerned about. These observations are meant for manual therapy assessment and treatment.
Exercise and neuromuscular re-education intervention is always required to maintain any improvement you make in the patient’s mobility. This requires further investigation into performance of core stabilizers such as the pelvic floor, lumbar mulitifidus and key hip mobilizers and stabilizers.
There are certainly patterns here that will also be addressed further. For now, posterior rotation dysfunctions may be seen in insufficient pelvic floor control and anterior rotations may be seen in insufficient lumbar multifidi control. The pelvic floor, because the segment is stuck in extension without sufficient pelvic floor strength to hold it in neutral with movement and load bearing and visa versa for the segment allowed to get fixed into flexion by insufficient multifidi control. I recognize this is very general but I’m trying to keep it simple. It’s a blog, not a thesis.
I find often when as lumbar rotational fixation has persisted for long enough, you will also find active limitation in hip mobility. The loss of lateral rotation seen with a given lumbar dysfunction and sacral torsion drives a limitation in hip flexion ROM. Then the loss of medial rotation seen on the opposite side will limit hip extension on that side. These are the combined motions of the hip required for full planar motions of the hip. Unless this issue is addressed, then the SI and lumbar deficits are likely to return. There will be future posts on the exercise intervention used to address these issues.
I feel that this combination of intervention, manual and home exercise instruction, is the key to resolving many conditions that cause pain and loss in function. Have you observed other patterns? How do you assess and treat SI dysfucntion?
Also, specific segmental mobilization removes the torsion of the sacrum and rotation of the innominate and restores the lumbar spine and femurs to neutral and so does a non specific muscle energy technique. What is a muscle energy technique doing? How do you know if you really fixed the problem? Maybe you just temporarily rewired the muscle tone. Why do patients have to repeat them so often? Why would you use one of those as opposed to specific muscle assisted mobilization? I think MET are far too temporary and your time is better spent teaching your patients how to self-evaluate and self-treat using muscle assisted mobilization. I’ll post my treatment interventions soon.
Until then, I welcome your comments. Are you satisfied with MET? Not me.