Sacroiliac Pain
The sacroiliac joints are the two large joints that join the sacrum (base of the spine) to the two large ilium (pelvic bones). These joints are prone to strain and injury from the time we can walk. They are a central to many common health problems that can affect us from head to toe. The sacrum is the hub of the body; the center of gravity and movement. The sacrum is not only involved with weight bearing and physical actions, but also with assisting in the movement of cerebrospinal fluid (CSF) which surrounds the brain and spinal cord. The spinal dura (the sheath containing the CSF that surrounds the brain and spinal cord) is firmly attached to the inner aspect of the sacrum. The role of the sacrum in the CSF system can account for many health effects of sacroiliac dysfunction.
Dr. Major B. DeJarnette, developer of Sacro Occipital Technique (S.O.T.) was an important pioneer in the chiropractic profession. Dr. DeJarnette identified three general categories of underlying physiological dysfunction which set the stage for many of our most common health disorders, illnesses and diseases. These categories relate to disturbance in the dural system (connective tissue of the central nervous system), the sacroiliac joints of the pelvis and the cartilage and discs. These three patterns of dysfunction were referred to as Category I, II and III and were associated with a specific disturbances in the body.
While the patient often presents with a particular pattern of symptoms (such as a specific pain) it is essential for both the doctor and the patient to remain focused on resolving the underlying pattern of dysfunction in spite of the occasional “impatience” of the patient and the temptation to the doctor to direct attention only toward the presenting complaint which doing so in most cases is a real disservice to the patient.
Normal
Normal physiology means that the body posture is balanced and symmetrical, the body is free of weight bearing, structural imbalance, neurological interference and cranial sacral respiratory dysfunction. The cranial sacral respiratory system is a wave-like motion of the cerebrospinal (spinal fluid) and meningeal (lining of the brain and spinal cord) system which produces spinal fluid and propels it around the brain and spinal cord. Alterations in normal structural balance are seen in overall misalignment in the body, uneven leg lengths viewed with the patient lying down, changes in specific muscle strength, muscle imbalance such as unilateral upper trapezius tension, sensory changes such as pain, numbness or tingling, changes in surface electromyography and paraspinal thermographic changes. Not all abnormal functioning in the body is perceived as pain. In fact, pain can be minor or even absent in the presence of significant underlying health problems.
A central issue in Category I and Category II is dysfunction of the sacroiliac mechanism. The left and right sacroiliac (SI) joints articulate the sacrum, the large triangular bone at the base of the spine, with the two large ilium of the pelvis. The sacrum moves in the SI joints in a nodding motion both forward (called nutation) and backward (called counter-nutation). The posterior or rearmost aspect of the SI joints are the weight bearing part of the joint composed of hyaline (smooth) cartilage like we see between other moving joints of the body like fingers, hips and shoulders. The anterior or forward aspect of the SI joints are composed of a synovial joint containing fluid. The anterior aspect of the SI joint allows for sacral nutation. Category I involved the anterior aspect of the sacroiliac joint while Category II involves the posterior aspect.
Category I
This pattern of dysfunction is often referred to as dural torsion. It is a disturbance in the cerebral spinal fluid system arising from the cranium and/or the sacrum which can create tension on the dural membranes which are the connective tissue surrounding the brain and spinal cord.
Signs of Category I include:
- Subtle front to back swaying of the body from when the patient is observed for a short time in the standing position indicating anterior sacroiliac joint fixation.
- SI joint fixation (hypomobility)
- Pain where the piriformis and gluteus medius cross
- Pain in the lumbodorsal fascia just lateral to the L4/5
- Whole-body axial torsion (compared with category two lateral unlevelling)
- Symmetrical joint dysfunction, generalized neurological dysfunction, lowered pain and body function thresholds, and somatovisceral and/or viscerosomatic (internal organ system) involvement.
- Increased first rib tension left and right
Category I Common Symptoms:
- Visceral (internal organ) disturbance
- Skin disorders
- Numbness in facial structures or extremities
- Insomnia
- Lower back pain
- Headaches
- Nervousness
- Weight problems
Category I Patient Responsibilities:
To assist in the process of correcting a Category 1 disorder there are several things you'll want to do as a patient.
- Exercise daily
- Get sufficient sleep
- Keep a positive mental attitude
- Maintain a well balanced diet
- Keep scheduled chiropractic appointments
Category II
Category II takes treatment priority over Category I. Category II is a disturbance of the weight-bearing system of the body, especially in the interosseous ligaments of the posterior sacroiliac joint. At this point the body's ability to maintain its postural alignment against gravity begins to suffer. Dr, DeJarnette said that there can be aspects of both an anterior and posterior dysfunction in a SI joint (both Category I and Category II). However, if there is even a small aspect of posterior hypermobility (Category II) then this usually should be the first priority of treatment prior to addressing any anterior SI joint fixation (Category I). This is because physical stability in the body is more important than maintain normal sacral motion (nutation).
Signs of Category II include:
- Subtle side-to-side swaying of the body from when the patient is observed for a short time in the standing position indicating posterior sacroiliac joint fixation.
- SI joint instability (hypermobility) tends to be unilateral
- Multiple lateral unlevelling of posture from the pelvis to the head.
- Inguinal ligament (groin) pain or sensitivity
- Inner and or outer knee pain or sensitivity (secondary to pelvic torsion or leg length inequality).
- Increased first rib tension on the shoulder and scalene muscle tension (thoracic outlet) on one side.
Category two leg lengths are determined by having the patient abduct their legs about 15 inches apart against resistance. The patient then relaxes while the doctor maintains traction on the legs and compares the relative position of the medial malleoli (inner ankle bones). Correction is then applied based on this inequality.
Category II Common Symptoms:
- Jaw problems
- Neck pain
- Ear pain, loss of balance
- Lateral headaches
- Shoulder, arm and hand pain
- Lateral chest pain
- Groin pain
- Lateral thigh pain
- Knee, ankle and feet problems
- Fatigue
- Lowered immune function (colds, flu)
- Hypoglycemia
- Menstrual problems
- Bed wetting
- Low back pain
Category II Patient Responsibilities:
To assist in the process of correcting a Category 1 disorder there are several things you'll want to do as a patient.
- Gentle exercise such as walking or swimming
- Avoid heavy lifting or bending
- Avoid sitting for extended periods
- Use ice rather than heat
- Avoid alcohol
- Avoid caffeine, nicotine and stimulants
- Avoid excess sugar and starch
- Avoid vacuuming
- You may need a supportive belt
- Keep scheduled appointments
Category III
The discs act like a shock absorber and a spacer between the spinal bones. When everything is working properly the discs provide enough space between the spinal bones for delicate spinal nerves to exit. When the body is out of balance the disc spaces can become compromised. This can pinch or irritate the nerve just beside it causing pain in the back or radiating pain that goes down the leg. A failure of the piriformis muscle (a key muscle in the buttocks that can also cause sciatic nerve pain) is also considered in Category III as is distortion of the pelvic iliofemoral complex.
Category III happens when the lower back cannot tolerate the physical stress placed on it. Category III is sometimes referred to as “failure.” This can occur from a sudden event such as lifting something heavy, or it can be a pre-existing weakness (such as an underlying Category II) which is aggravated. Correcting a Category III takes first priority over correcting an underlying Category II and/or Category I.
Signs of Category III include:
- Low back pain
- Pain down the back of the leg
- Burning sensation down the back of the leg
- Pins and needles in the leg
- Tightness in the leg
- Numbness in the leg and back
- Poor bowel or bladder control
- Pain on sitting, rising, bending, coughing or sneezing
- Cold extremities
Category III Patient Responsibilities:
- Avoid sudden twists or turns or bends
- Lift only with your back upright
- Use ice wrapped in towel for 10-20 minute intervals as often as possible
- Reduce alcohol, caffeine, nicotine and sugars
- Walk regularly to tolerance
- Sleep on your back with a pillow under the knees to help relieve pressure
- Keep scheduled appointments
Improving your condition in any Category is a process and not an event. It took some time for you body to get this way, and it may take a little time to reverse the problem. In a world of instant drug pain relief you must remember that actually correcting a problem is different from merely masking the symptoms.
Dr. Philip Greenwood, D.C.
Murrieta, California
