Sacroiliac Joint Dysfunction - Diagnosis And Treatment

There is a common complaint from runners in the practice – ‘ it’s my hamstring – it is tight and will not let go – just at the top! ’ This is followed by the claim ‘ my leg does not come through very well. ’ Or ‘ It’s like running in treacle! ’  

The main reason for this is a problem in the pelvis and in particular the sacroiliac joint. The pelvis is made up of three bones - the sacrum in the middle and an Ileum on each side. The sacroiliac joint is found at the back where the two ileums attach onto either side of the sacrum.    

The sacroiliac joint is unusual in that it is two irregular surfaces of bone that are held together by a thick fibrous skirt. It is not a ball and socket like the hip.  

There is little motion, approximately 5 degrees maybe, as the leg come from behind to in front. However it is the top end of a long lever, the leg. Physics tells us that a small amount of motion at one end of a lever has a large effect at the other. If therefore the sacro iliac joint becomes jammed and does not move fully the effects on the leg are dramatic.    

The main symptoms are:

• Tightness in the upper hamstring.
• Tightness in the gluteal or buttock region.
• Possibly soreness in the lower back, but not often.  

The history is often not clear. There is rarely an ‘ouch’ moment. However episodes in my experience are often caused by:

• Fast downhill running
• Running with a poor core and the pelvis tipping forwards
• Lack of form at the end of a hard session
• A hard stumble or trip

Self-assessment is difficult. There is a certain skill and experience needed. If you see a physio they should look at the pelvis motion with bending forwards and sideways and then with single leg lifts – knee to chest. They should be looking at the back of the pelvis and noting how the bones move.

However, there are a few things that can be seen at home. None of these tests are perfect but they enable you to build a picture.  

Flexion Test

You can look at the level of the pelvis in flexion as in Picture 2. The bones should be level. Ensure you start with the feet level too as this will affect it.    

You will obviously need someone to do this for you. The thumb position is in the ‘dimples of Venus’ which are the small hollows either side of the pelvis (see Picture 3.) The tester will feel a point of bone which is the ileum and it is this point that the tester needs to follow as patient bends forwards.  

The bones should stay level. The side that rises higher is typically the ‘stuck’ one.  

Stork Test

This test is looking at one side of the pelvis for movement of the ileum (outside bone) on the sacrum (inside bone)  

The tester places one thumb as above in the dimple and feel the ileum (as in Picture 4.) Place the other thumb centrally on the sacrum. Ask the patient to lift the knee high up to the chest. The outside thumb should drop down as the ileum rotates backwards. Compare it to the other side a few times. If on one side the bone does not drop backwards and the pelvis seems to hitch up, then this is the joint that is not working properly.

Leg length

There is often an ‘apparent’ leg length discrepancy – tested in lying a sitting. This is often confused with an ‘actual’ leg length change and I have seen many athletes with heel wedges put in place for what is a normal leg length. This does not help.

You can self-test this by laying on your back as straight as you can and your heels and ankle bones together. Typically, they are pretty level. Sit up carefully and note if the bones alter their level to each other. A shortening leg will indicate the SIJ is not rotating properly on this side.

These three tests will hopefully build you a picture. Certainly if you find three out of three are positive you are on the right lines. Two out of three then go with it but if only one is there then consider other options.

The common problem with diagnosing pelvis dysfunctions

There are something like 24 odd different types of pelvis dysfunctions and you need to be an experienced physiotherapist to diagnose them properly. However there is a very common dysfunction seen in runners. This is where the Ileum (the outside bone) becomes rotated forward on the sacrum. (The central bone). The tests above are the simplest for the lay person to try to diagnose themselves with.

The majority of these joint dysfunctions require mobilisation of the sacroiliac joint by a Physio used to dealing with runners. Typically, this may be done side lying or on your back and usually involves the Physio putting pressure though the pelvis with the knee towards the chest. There are several ways to do it though.

The following exercises however are designed to ease this condition. They will not hurt you if it is not the problem and you have incorrectly diagnosed but they may well help. Try them for a few days but if there is no improvement in this time then seek help.

Once the pelvis has been mobilised then follow the instructions given by your physio which will be similar to these exercises.

Hug your knee to your chest and hold tight around the knee as shown in Picture 5. Push hard with your leg into your hands for 10 seconds, then relax, pulling the knee tight again and repeat. The pressure comes from your hip and bum. You are not straightening the knee.

This can be done sitting or lying and needs to be repeated hourly about 15 times. The object is to use your bum muscles to mobilise the sacroiliac joint. You will not feel much apart from strain in the bum.

In sitting, cross the foot of the hip to be stretched to the outer side of the other knee. Hug the bent knee with the opposite hand. (So if it is your right hip to be stretched, put the right foot to the left of the left knee and hug the right knee with your left arm.)    

Place a tennis ball or hard cricket / hockey / dog ball in the buttock and lean towards it - as shown in Picture 6. Fiddle with the exact position. Somewhere between the outer hip bone and the bone you sit on. Look for the most painful spot (!) and then work the ball into it for a couple of minutes.    

The object is to loosen the deep hip muscles which go into spasm whenever there is a sacroiliac joint dysfunction.  

Picture 7 shows the direction to bend – away from the symptomatic side. You are more effective if you hold your core in really tight, tipping the pelvis backwards. This focuses the stretch into the area of the back covered by the arrow. 45 seconds 3 times, several times a day.

Using a roller or a can, roll on the upper hamstring through the tight areas, keeping the back straight as possible (see Picture 8.) 2 minutes 3 times a day.

Can I run with a sacroiliac problem?

The big question and the answer is usually yes. Running actually helps to mobilise a sacroiliac joint - once it is moving properly. If it is not then it will irritate it.  

Try the above but if in doubt please seek help. These conditions can linger for many months undiagnosed and cause lots of knock on issues including knee, shin and Achilles issues. However, they are simple to treat .