It is a typical complaint in the field of massage therapy: “My back hurts all the time!” As bodyworkers, many of you have probably experienced a patient with a complaint of low back or hip pain. While the sources of back pain are numerous, you may have treated a patient with Sacroiliac Joint Syndrome (SIJS) yet not been aware it existed. The reason? SIJS is a major source of back and hip pain, yet it is a very difficult syndrome to diagnose and treat. Chances are, your patient’s orthopedist probably missed it. But just because it was not diagnosed doesn’t mean it cannot be helped.
There are many things a massage therapist can do to help a patient with SIJS. While massage can be very effective in pain relief, the only way to begin to correct SIJS is to examine structure as it relates to soft tissue. If the tissue is hypertonic and contracted, it must be released and lengthened. Continual shortened tissue only creates more dysfunction. The ligaments of the hip must be considered along with the muscles, and the only true way to get to these ligaments is by proper stretching.
Clinical Flexibility and Therapeutic Exercise (CFTE) is a series of exercises made up of flexibility and manual therapy protocols designed to increase range of motion in the joints and strengthen weak musculature. In the CFTE protocol there are three steps to consider in treatment:
Using CFTE, the therapist is concerned with solution more than pain. The CFTE therapist asks this question each time she treats a patient: How can I solve this problem and teach the patient at the same time? Many patients have suffered a long time with pain. In my own practice, eighty-five percent of the patients who come to me have tried many other modalities in health care to help their conditions. Very few are ever taught how to prevent injuries and pain, or even why it exists. The idea with CFTE is to help the patient understand his problem while treating him.
How do we know the patient has SIJS? When I come across a patient with low back pain, or for that matter, hip pain, I assume SIJS. From a kinesiology point of view, any weak or tight muscle has a negative effect on the body. In the initial assessment, which includes verbal and physical protocols, the therapist must get a basic handle on the integrity of the SIJ. There are several simple manual tests that were designed to assess SIJ dysfunction, and one of these, called the Patrick’s Test, is actually part of the stretching protocol in CFTE. If the patient complains of pain around the sacroiliac joint, there may be pathology in the joint itself. I personally prefer this test to all others, as it goes in line with the protocol of Active Isolated method of flexibility I use to treat SIJS. This test can be used to detect pathology in the hip as well as the sacroiliac joint, but it is extremely useful in assessing a patient’s range of motion, as well as the integrity of the soft tissues. The patient is supine as the therapist places one foot over the opposite knee. In this position, the hip is now flexed, abducted, and externally rotated. The therapist applies a gentle pressure over the knee, pushing the leg to the table. If pain is experienced, there may be problems with the joint; however, tenderness in the inguinal ligament can often fool the therapist. To assess this, run your hand along this broad ligament located on both sides of the top of the iliac crest and test for tenderness. It is important for the therapist to know if any of these movements initiates pain, and then treatment can continue. If there is pain, ask the patient where she feels it. Pain in the joint itself may require X-rays or an MRI to detect damage to the bone tissue. If this is the case and there are no existing films, have the patient get them before you proceed with your treatment. You can discuss the results with another trained professional or the physician.
There are over fifty movements in the CFTE protocol for flexibility, and the CFTE work employs Active Isolated Stretching (AIS) as the method to open soft tissue. A stabilization belt is used for each technique, to help keep the pelvis stable. With AIS there is no passive movement, but one hundred percent contribution from the patient. Also, instead of longer holds (e.g., twenty seconds), in AIS the stretch is only held for one to two seconds. This way we cause no further trauma to the affected tissue and structure. If SIJS is suspect, flexibility is a very important consideration. Remember, the range of motion for the SIJ depends on the surrounding muscle tissue as well as the ligaments and tendons of the joint itself. As in massage therapy, our goals are to open soft tissue and restore blood flow. But restoring range of motion in the pelvis is vital to correct any imbalances that exist with SIJS. First, we must start with the larger superficial muscles of the hip.
The hamstring’s attachment along the ischial tuberosity must be considered in treatment. The line of pull will tilt the pelvis posteriorly and can cause severe imbalances in the SIJ. A shortened biceps femoris can cause sciatica and low back problems because of excess strain on the low back, and it also has a direct relationship with the sacrotuberous ligament on the sacrum.
The adductor group must also be considered. The adductor group’s origin at the surfaces of the pubis, and its insertion at the linea aspera of the femur provides a dynamic pull on the pelvis and low back. Limited (tight) adductors will cause low back pain and disrupt the balance of the SIJ.
I have seen vast improvements in chronic SIJS after only a few treatments. Treating it is complex, and it does take more education and the correct protocol to solve. Massage therapists should realize that ligaments are very often involved with muscle and fascia, and imbalances in the body must be corrected. One tight and compromised muscle or ligament is enough to skew the pelvis and, in time, cause complete dysfunction in the entire body; ligaments and muscles are very difficult to treat without a flexibility protocol. With the right knowledge, you, too, can reverse SIJS.