Sacroiliac Joint Displacement
John, a 30 year old landscape gardener, had a two year history of back pain, and had seen a number of practitioners. The pain was in the right sacroiliac area, radiating to the right buttock only, not into the thigh.
Characteristically, the pain was a constant gnawing on sitting, deep in the buttock, eased by standing or lying, but not exacerbated by coughing or sneezing. Sitting comfortably on a hard chair was difficult - sitting partially off the seat was more comfortable. Turning over in bed at night could bring on the pain for a short while.
The pain had started immediately after lifting a large rock and shifting his weight on to his right leg, and had been present every since.
Analgesia, consisting of NSAIDs, Paracetamol or Codeine, gave only temporary relief.
There was no significant past medical history, and specifically no inflammatory joint disease.
Extensive investigations, including FBP, CRP, lumbar and sacroiliac x-rays, and an MRI scan, had shown some degenerative spinal vertebral disease, but none to account for the symptoms.
Examination revealed straight leg raise of 90 both sides, and slightly decreased right side flexion. Palpation of the sacroiliac joint gap showed the right to be 0.5 cm lower than the right in erect posture, whilst full forward flexion allowed it to rise 1 cm above the left. (Piedallu test).
Lying prone, pressure down the vertical axis of the right femur towards the acetabulum (piston test) in full hip flexion/abduction, flexion/abduction and 60 flexion in neutral, all elicited pain the right sacroiliac joint.
Diagnosis: Sacroiliac joint displacement
Anatomy: The sacroiliac joint is one of the strongest joints in the body, and is a fibrous joint. The mountains and valleys of the two irregular surfaces fit comfortably into each other (Medical students are taught that the joint does not move. However, physiologically, the joint does move slightly). The fibrous ligaments holding the joint together can loosen in pregnancy under the action of progesterone, or can be disrupted at any time by a powerful force acting on one sacroiliac joint only.
Forceful opening of the joint may result in the joint relocating, but with the 'mountains and valleys' no longer in snug comfort, but with the jigsaw pieces jammed together uncomfortably.
Such a force occurs when a weight is being carried in the arms, and suddenly one leg slips or gives way. My own was put out whilst wheeling a heavy wheelbarrow of logs, and my foot slipped off the verge of the path. Replaced by a skilled physiotherapist at Guy's Hospital, it was disrupted again pulling forcefully on a rope on a sailing ship, when suddenly the other six people on the rope let go, allowing me to take a large force on my arms, transmitted down through to one leg only.
My symptoms were exactly the same as those in the case above, and were relieved by replacement by a physiotherapist.
It is important to diagnose correctly which joint is displaced, or symptoms may present on the contralateral side.
Replacement is a simple manouevre. It involves using the femur as a lever, patient lying prone on the floor. The ankle of the affected side is placed just above the knee of the opposite leg, the affected thigh/knee fully abducted, and the operator gently holds affected knee and contralateral anterior iliac crest. The operator takes up the slack, and then gives a gentle over pressure to gently separate the joint. Invariably, the joint goes back correctly. However, the over pressure results in the ligament being slackened.
The patient rises from the floor on two legs together, feet against buttock and helped to upright.
Relief of pain is invariably immediate.
For the next few weeks, the joint is vulnerable to any weight being taken on only one leg, especially that of the treated side. The patient is advised to:
- lead up stairs one at a time, with the untreated side, 'dot and carry one',
- to only get into a bath by sitting on the edge and lifting legs over one at a time,
- get into a car by reversing into the seat, then lifting legs around,
- not to bend and twist, or to reach out to one side when standing.
The overriding principle is that the pelvis is only stable (and only to heal from the slackened state after being mobilized) when both feet are square on the ground together, and the torso is pointing the same way as the feet.
It is advised to check the joint a day or two after replacement.
Some chiropractors may have a different manipulation technique to relocate the displacement.
Caution - this manoeuvre should only be carried out by qualified persons with appropriate training.
John was referred to an appropriately qualified manipulator.
Case two. Martin, age 56, had right buttock pain for many years, together with other back pains. Extensive investigation had not helped, and he remained dependent on largish doses of codeine several times a day. As with John, the pain was in the right sacroiliac area, radiating to the right buttock only, not into the thigh.
Characteristically, the pain was a constant gnawing on sitting, deep in the buttock, eased by standing or lying, but not exacerbated by coughing or sneezing. Sitting comfortably on a hard chair was difficult - sitting partially off the seat was more comfortable. Turning over in bed at night could bring on the pain for a short while. The pain was present for much of every day.
Piedallu test showed that the contralateral (left) sacroiliac joint was displaced, confirmed by piston test, despite the fact that the symptoms were on the right.
The left joint was replaced, with immediate relief of the chronic constant nagging toothache in the right buttock.
Two days later the joint was still in place (ie. had not been redisplaced) and months later he remained free from this aspect of his pain, and was using considerable less analgesia.
Case three. Julie, age 36, had had chronic left inner thigh pain since childbirth some three years before, when she had had a fast labour. Painkillers helped little, and she was unwilling to take them.
I suspected an unusual adductor tendonitis form the story, and did not recognize the symptoms. Specifically, buttock pain was not a particular feature.
Examination showed SLR of 80 both sides, reasonable forward and right side flexion, slightly diminished left side flexion, but, to my surprise, a positive piston test and left Piedallu.
Diagnosis was therefore a displaced left sacroiliac joint.
It was replaced, with immediate relief of pain. At followup several weeks later, Julie remained pain free.
Sacroiliac joint displacement is a condition that occurs as a result of trauma, as well as due to slack ligaments in pregnancy. Diagnosis is entirely clinical, on the basis of history and clinical examination. Manipulative therapy is curative. X-rays and CAT or MRI scans fail to reveal any abnormality in the affected joint, and may mislead by uncovering other co-existent pathology. Pain may be felt in the contralateral side, but simple examination will elicit this.
Treatment is simple and curative, with the proviso that the patient takes care for the first few weeks not to put the joint 'out' again.
Unfortunately, many clinicians including doctors and physiotherapists are not taught about this - in my case I knew the condition from personal experience, and so was able to look for it in each of these cases. There must be many other medical conditions where a happy coincidence of patient and a clinician's personal experience helps both!