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14 Articles in Volume 9, Issue #7
Anomalous Opiate Detection in Compliance Monitoring
Anticipating Biotechnological Trends in Pain Care
Continuous Lumbar Epidural Infusion of Steroid
Disordered Sacroiliac Joint Pain
Efficacy of Stimulants in Migraineurs with Comorbidities
Hand Tremor with Dental Medicine Implications
Helping Patients Understand the
Non-surgical Spinal Decompression (NSSD)
Pain Management in Nursing Homes and Hospice Care
Patients Who Require Ultra-high Opioid Doses
Relief of Symptoms Associated with Peripheral Neuropathy
Share the Risk Pain Management in a Dedicated Facility
The Multi-disciplinary Pain Medicine Fellowship
Thermal Imaging Guided Laser Therapy: Part 2

Disordered Sacroiliac Joint Pain

The partial displacement or dislocation of the sacroiliac joint is a poorly understood and seldom diagnosed condition that may be responsible for a number of back pain or upper body painful conditions.

The disordered sacroiliac joint is hypermobile due to abnormal laxity of damaged ligaments that tether together the bones that form the joint.1-5 The ligament that seems to be most commonly injured is the iliolumbar ligament.3 Damaged ligaments allow the disordered sacroiliac joint bones to partially dislodge when physically stressed. In the upright body, this joint usually bears over 100 pounds or more. It is critical that this disorder be recognized because it is not only a common cause of chronic back pain and sciatica, it may be associated or possibly even causative of a number of common musculo-skeletal conditions (see Table 1). The most common manifestation is chronic low back pain and it may be the cause of between 10 and 30% of such cases.

Table 1. Medical Conditions Associated with Sacroiliac Joint Disorder
  • Chronic headache pain
  • Temporal mandibular joint (TMJ) pain
  • Chronic neck pain
  • Cervicobrachial syndrome (arm pain)
  • Thoracic outlet syndrome (TOS)
  • Lateral epicondylitis (aka tennis elbow)
  • Scoliosis (functional) with pain
  • Fibromyalgia
  • Chronic low back pain
  • Chronic lower abdominal pain
  • Chronic hip pain
  • Chronic urinary frequency
  • Chronic groin pain
  • Chronic sciatica

Causation

Some common causes of disorder of the sacroiliac joint are mundane motor vehicle accidents, mechanical falls, and lifting injuries involving torsion of the lower spine.4 Nurses and nursing aides who lift patients are particularly prone to accidental sacroiliac joint injury leading to permanent sacroiliac joint ligament injury and hypermobility. People who work on and fall from ladders and who do lifting and pulling in construction are also prone to accidental and permanent injury of the sacroiliac joint. Sacroiliac joint ligament injury and subsequent laxity is a unifying etiology that explains how these mundane accidental injuries can result in a biomechanical disorder.

Another mundane cause of sacroiliac joint hypermobility is the hormones of pregnancy, which enable the pelvic ring to be more expandable to allow the fetus greater ease of passage during birth. Many women experience chronic low back pain after childbirth due to sacroiliac joint laxity caused by the hormones of pregnancy. After parturition, the sacroiliac joints normally revert to a tightened and locked position. In about one out of five women, full tightening does not occur and these women develop varying intensities of chronic low back pain.

Another symptom experienced by 10-15% of women with sacroiliac joint partial displacement is urinary urgency/ frequency.4 These women have to go more often than most others. These symptoms arise from disruption of function of nerves that control the urinary bladder. Anatomically, these nerves course over the anterior sacroiliac joint in the posterior pelvis, where they form a plexus. When an injured sacroiliac joint is hypermobile, these nerves are jarred and tugged. This jarring effect irritates nerves, causing them to fire and to stimulate the bladder.

How a Hypermobile Sacroiliac Joint Causes Symptoms

A curved spine (scoliosis) represents the unconscious proprioceptive functions of the nervous system, and the muscles and tendons it controls, to swing body mass towards a medial center of gravity. This is necessary wisdom of the human body.

Cantilevering of the head is another unconscious brain-driven proprioceptive attempt to provide a counter-weight to tilted upper-body mass. A head weighs about 12 pounds and each arm about 20 pounds.3 The upper body above an unstable sacroiliac joint can weigh 100 pounds or more. The muscles of the upper body are charged with keeping all of these weights upright and symmetrical about the central axis of the spine. A normal body distributes weight evenly from side-to-side. A body with an unstable sacroiliac joint cannot because the spinal column totters upon an unstable foundation.

Asymmetric shoulders are common in “fibromyalgia” and neck-shoulder patients and further reflect an unbalanced spine. Sacral slippage occurring in one of the sacroiliac joints causes this asymmetry. The tipped shoulder girdle results from a curved spinal column stationed upon a rocky and unstable pelvis—all the while attempting to maintain a medial center of gravity of the upper body mass. Even the arms, which unconsciously splint and raise (flex at the elbow) to accommodate tilted shoulders, develop pain at the elbows (tennis elbow a.k.a. lateral epicondylitis) where arm muscles attach.

An upright body is a complex symphony of momentary and ever-shifting movements and adjustments—all finely tuned to maintain a centrally balanced spine and a body mass symmetrically hung on each side of the spine which functions as an upright support or post. When body mass is chronically off center, the spinal column and muscles of balance are chronically stressed, spastic, and full of pain, i.e., the biomechanical phenomenon that gives rise to upper body pain disorders and fibromyalgia symptoms.

Diagnosis of a Biomechanical Disorder

Over 40 years of practice, I have developed a step-wise protocol to diagnose a biomechanical disorder and I pass this on.

  1. First, posture is inspected with the patient in a neutral relaxed upright stance. Fingertips of one hand are often closer to the floor and indicative of a sloped shoulder on that side. A yardstick can be used to quantify this finding.
  2. Note is made as to which side the head is customarily tilted because the head functions as a counterweight to lower body parts swayed away from the body’s midline center of gravity.
  3. The trapezius muscle is the large muscle at the base of the neck and in the upper back. In “fibromyalgia” patients, the trapezius muscle is often thicker and spastic on one side, usually the side opposite the side the head is tilted towards. This observation is made by rolling the borders of the trapezius muscle (at the base of the neck) between your index finger and thumb, and by judging its thickness. Isometric stress of the trapezius muscle supporting a tilted head (about 12 pounds) explains this hypertrophy.
  4. The upright spine is curved (scoliosis) in an “S-shaped” curve. This finding is discovered by the examiner slowly drawing his/her fingers down the sides of the spine and observing deviations from vertical. Often, the lower spine will be offset to the right of the upper spine. A curved spine represents the body’s innate wisdom at maintaining a medial center of gravity when uptight and supporting over 100 pounds above an unstable foundation: an injured and disordered pelvis (more on this below).
  5. When the examiner’s index and middle fingertips are planted on each of the “bikini dimple” regions in the low back and held there while the patient bends over forward, the fingertips will be observed to ride upwards. During this upward excursion, one fingertip will be observed to ride higher (more towards the head) than the other. The side on which the fingertip rides higher signifies underlying sacroiliac joint disorder, and the abnormal movement of the underlying bones is termed counternutation. This is called the “Forward Flexion Sign.”
  6. Next, while the patient remains bent over forward, the examiner pushes firmly into the region of the higher finger. This maneuver usually arouses exquisite pain which is abnormal. This pain (referred to as the “Fortin Sign”) indicates the pre-sence of, and is pathognomonic of, an underlying disordered sacroiliac joint.
  7. As the patient lies prone face down, the examiner draws two fingers—one on each side of the spine—down the spine. The spine will be observed to be straight as opposed to the curved spine observed while upright. This observation confirms that scoliosis observed while upright is a functional disorder rather than fixed and organic. It also demonstrates the influence of gravity on the biomechanics of the human body.
  8. When the patient lies on a firm surface, like the floor, and goes from supine (lying on the back) to a seated position and with legs horizontal, the leg on the side of a disordered sacroiliac joint will often become longer (occasionally shorter) that the normal side. This is the “Long Leg Sign” and comports with sacroiliac joint disorder. Leg lengths are monitored by placing sharpie marks on the inner bony prominence of each ankle and watching how they line up. A ruler can be used to measure the differential. The leg is attached to the pelvis and a loose and rotating (counternutating) pelvis, caused by sitting up, carries the attached leg posteriorly and results in a functional change in the length of the leg.
  9. Examination of the soles of the shoes usually discovers a predominant wear pattern on the rear and outward edge of the shoe on the side of the disordered sacroiliac joint. This excessive wear is due to the lateral foot on this side striking the ground harder with each step, and because the person tilts to this side when upright and walking. This occurs because of sagging within an injured, disordered and hypermobile sacroiliac joint on this side (see discussion below).
  10. Next, the patient sits upright on a firm surface with legs horizontal. A one inch thick book (size of a Gideon Bible) is placed under the ischial prominence (the “seat bone”). When the book is placed under the side opposite the side of the disordered sacroiliac joint, this causes the leg on the side of the disordered sacroiliac joint to become shorter by 1-2 inches. When the book is placed under the disordered side the leg lengths remain equal. This phenomenon is called the “Badgley Book Sign” and, in the author’s experience, is the most dependable sign of underlying sacroiliac joint disorder.5 The one inch book bolster tilts the upper body just enough to place greater weight onto the loose sacroiliac joint to force it into counternutation and cause it to draw the attached leg rearward—thereby functionally shortening the attached leg.1
  11. Other signs of biomechanical abnormalities are the “T-shirt Sign,’ whereby the t-shirt rim is closer to the neck base on the side of the higher shoulder. Another is the “Pant Cuff Sign” whereby the rear part of the rim of the cuff on the “short leg” side is more frayed that the rim on the other cuff—providing further evidence of functional shortening on the side of the disordered sacroiliac joint. Sagging of the upper body on the side of the sacroiliac joint disorder causes greater definition of the fat fold (“Fat Fold Sign”) above the waist in the flank on the side of the sacroiliac joint disorder. The “Pony-Tail Sign” manifests as the person walks away, and the pony-tail will be observed to swing predominantly to the side of the disordered sacroiliac joint. These four signs were discovered by the author during his development of the BFD method of diagnosis.
  12. Persons with a loose sacroiliac joint preferentially sleep on the side away from the disordered sacroiliac joint and with their upward leg flexed at the hip and knee and up over something like a pillow or their spouse. The reason for this preferred position is that it allows the disordered sacroiliac joint to float into a neutral and relatively non-stressed position, whereupon there is minimal stretching of the damaged and loose ligaments of the joint. Stretching of damaged and lax sacroiliac joint ligaments hurts and wakens them from sleep.

Treatment

At this time, there is no standard treatment for sacroiliac joint partial displacement.6 Physicians currently use a wide variety of treatments including anti-inflammatory agents, physical therapy, and corticoid-anesthetic injections agents under fluoroscopy. Certainly shoe lifts and other prostheses may be indicated.

Summary

Sacroiliac partial displacement or dislocation is a poorly understood and seldom diagnosed condition. It causes severe biomechanical, upper body dysfunction that can manifest and masquerade as any number of pain syndromes and fibromyalgia. Physicians should attempt to diagnose it in any patient with back pain or upper body painful conditions. It is the author’s belief that treatment for this condition is not well defined because it is so seldom diagnosed and it is poorly understood as a “stand-alone” disorder. It is the author’s desire that his diagnostic methods lead to more diagnoses of this condition and a refinement of treatment strategies.

Last updated on: December 10, 2012
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