Michael T Cibulka 1992; 72:917-922. PHYS THER.

The Treatment of the Sacroiliac Joint Component to
Low Back Pain: A Case Report
Michael T Cibulka
PHYS THER. 1992; 72:917-922.
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The Treatment of the Sacroiliac Joint Component to
Low Back Pain: A Case Report
This case report describes the treatment of a patient who had symptoms and signs
suggestive of a samiliac joint component of low back pain. The patient developed right-sided low back pain without provocation. He appeared to have sacmiliac joint dysfinction, excessive right hip lateral rotation, and limited right hip
medial rotation. The patient's habit of crossing his right leg over his left leg while
sitting toas believed to have contributed to the excessive lateral hip rotation. 4frer
treating the sacroiliac joint and restoring symmetrical hip rotation, the patient no
longer complained of low back pain. This case report suggests that asymmetrical
hip rotation may contribute to what is often called a sacroiliac joint component
of low back pain. [Cibulka MI: The treatment of the sacroiliac joint component to
low back pain: a case report. Pbys %. 1992;72:917-922.1
Key Words: Low back pain, Manipulation, Muscle imbalance, Sacroiliacjoint.
The sacroiliac joints are often considered a source of low back pain1-7
Debate has continued over the existence of sacroiliac joint dysfunction.
Some view the sacroiliac joint as an
insignificant contribution to low back
pain,&l0whereas others believe the
sacroiliac joint plays a major role in
low back pain.'-7 I believe that the
sacroiliac joint contributes to low
back pain.ll
Studiesl2J3 have shown a relationship
between the sacroiliac joint and limited hip mobility. Dunn et all2 reported that in multiple patients pyogenic infection of the sacroiliac joint
resulted in limited hip mobility, limited straight leg raising, and pain
when the pelvis was compressed (ie,
by application of pressure in a posterior and lateral direction over the
supine patient's anterior superior iliac
spines [ASISs]).IaBan et all3 found
asymmetry in hip mobility with a
reduction in abduction and lateral
(external) rotation in patients with
sacroiliac joint dysfunction.
Studiesl4-16have shown a relationship
between low back pain and asymmetrical hip rotation. Fairbank et all4
found limited hip rotation in students
with back pain more often than in
students without back pain. Mellinl5
found a significant correlation between recurrent low back pain and
limited hip medial (internal) rotation.
Ellison et all6 reported the relationship between asymmetrical hip rotation and low back pain in patients
with diagnoses of lumbar strain, disk
herniation, sacroiliac joint dysfunction,
and avulsion fracture. Ellison et al
reported that patients with low back
pain usually had more lateral hip
rotation than medial rotation and that
they had a greater frequency of excessive hip rotation than did those without low back pain.
The purpose of this case report is to
describe the treatment of a patient
MT Cibulka, FT,OCS, is President and Physical Therapist, Jefferson County Rehabilitation and
Sports Clinic, 430 S Truman Blvd, Crystal City, MO 63019 (USA).
who appeared to have a sacroiliac
joint component to low back pain and
who also had unilateral asymmetrical
hip rotation (ie, more lateral than
medial).
Intendew Data
A 32-year-old physically active male
accountant, 172.7 cm (68 in) in height
and 72.6 kg (160 Ib) in weight, was
referred to physical therapy with a
complaint of unilateral, right-sided
low back pain. He did not report
buttock o r leg pain. The patient completed a pain drawing of his perceived pain o n his initial visit (day 1)
(Fig. 1).The patient reported waking
up with right-sided low back pain and
stiffness, which had persisted for the
last 4 days. He could not remember
any trauma or acute injury to his low
back. He reported that he developed
similar right-sided low back pain and
stihess, usually lasting 2 days, every
month for the past year. The patient
reported, however, that this episode
of low back pain and stiffness was
worse than his previous episodes,
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The patient reported that his preferred sleeping posture was lying
prone with the right knee flexed and
the hip laterally rotated (Fig. 2). He
reponed experiencing stiffness, but
no pain, in the right side of the low
back when bending over to wash his
face o r brush his teeth (Fig. 1).
Coughing o r sneezing did not increase his low back pain. He reponed
that his work did not result in any
increase in pain except for an occasional pain when moving from a
sitting to a standing position.
Throughout my interview of the patient, I observed that he repeatedly
crossed his right leg over his left leg
(Fig. 3).
Physical Examlnatlon Data
On the first day the patient was seen
in therapy, he perceived his low back
pain as moderate. This assessment
was based on the patient's Oswestry
low back pain disability questionnaire
score of 34. The Oswestry questionnaire measures perceived pain o r
disability with a score ranging from
0 to 100, with 0 the least possible
perceived pain and 100 the worst
possible perceived pain."
Figure 1. The location of the patient's low back pain.
prompting him to seek medical
attention.
Figure 2. Laterally rotated sleeping
posture of the right hip.
86/918
The patient also reported that he
developed right-sided low back pain
after walking or running distances
greater than 0.4 km (0.25 mile). The
patient reponed that, while running,
he developed stiffness in the low back
(Fig. 1) during the first 0.4 km, but
that his stiffness subsided and his low
back felt better after completing his
daily 6.4-km (4-mile) run. Sitting was
not painful, but he complained of an
occasional pain (Fig. 1) when he
moved from a sitting to a standing
position. The patient complained of
almost daily morning stiffness (Fig. 1)
that would last approximately a half
hour to an hour after getting out of
bed.
Visual inspection of the standing patient showed no apparent deformity
of the lumbar spine in the frontal o r
sagittal plane. Active spinal motion
was visually assessed, but I did not
measure the motion with a goniometer. Active movements were assessed
to obtain a gross assessment of the
patient's active range of motion
(AROM) of the trunk and to determine which specific movement produced pain6 The patient reponed that
his trunk AROM in forward bending
was painless, and he could touch his
toes with both knees completely extended (0" of extension). He did,
however, report stiffness (Fig. I), but
no pain, in the low back upon returning from forward bending. The
forward-bending motion appeared
smooth without evidence of muscle
guarding. Backward bending was
painless, and the patient appeared to
have full AROM. Left side-bending was
also painless. The patient could reach
his lateral knee joint line with his
Physical Therapy /Volume 72, Number 12December 1992
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positive standing flexion test purportedly indicates limited movement of
the ilia on the sacrum, displaying
limited sacroiliac joint motion on that
side.' The tests that suggest sacroiliac
joint dysfunction, however, are known
to yield measurements of questionable reliability.18
Palpation of the bony landmarks
while the patient sat on a level surface
showed that the right PSIS appeared
lower when compared with the left
PSIS.'9 The presence of a lower right
PSIS suggests that the right innominate bone may be rotated posteriorly
on the sacrum, whereas the left innominate bone is supposedly anteriorly rotated.llJ9
Flgure 3. Luterally rotated sitting
posture of the right hip.
fingertips. On right side-bending, he
could also reach his lateral knee joint
line with his fingertips but he complaineti of low back pain and stiffness
at the end of movement. The tendency to side-bend toward the side of
the low back pain is common in patients who are believed to have a
sacroiliac joint component to low
back pain.'
Palpation of the pelvic landmarks
while the patient stood with the knees
fully extended and the feet a shoulder
width apart showed a high right ASIS
when compared with the left ASIS.
Palpation of the posterior superior
iliac spine (PSIS) indicated that it was
lower on the right than on the left. A
high right ASIS and a low right PSIS
are said to indicate a right posterior
rotation of the innominate bone (ie,
sacroiliac joint dysfunction).l When
palpating the PSIS on forward trunk
bending, the right PSIS appeared to
move more superior than the left
PSIS. This finding is indicative of a
positive standing flexion test.lJ1 A
When palpating the region medial to
the right PSIS, I noted tenderness
and was able to reproduce the patient's pain. Tenderness medial to
the PSIS is said to suggest sacroiliac
joint pathology.20 Manual muscle
tests of the hip flexors, the quadriceps femoris muscles, the ankle
joint dorsiflexors, the plantar
flexors, and the extensor hallucis
longus muscles showed Normal
muscle grades.21 Patellar tendon
and ankle reflexes were bilaterally
symmetrical.
Left straight leg raising, measured
with a fluid-filled goniometer,* was
painless for 90 degrees. During right
straight leg raising, the patient complained of right-sided low back pain
at 75 degrees of hip flexion. Pain
beyond 35 degrees is said to indicate
mechanical dysfunction at a lumbar
joint or a pelvic joint.' The patient's
leg lengths were examined, with the
patient in the supine position, by
comparing the level of the inferior
aspects of both medial malleoli. The
right leg appeared shorter when compared with the left leg. The reliability
of this measurement technique has
not been demonstrated. While holding my thumbs just distal to both
medial malleoli, the patient was asked
to sit up. The apparently short right
'Chattanooga Corp, 4717 Adarns Rd, Chattanooga,TN 37343.
Physical Therapy /Volume 72, Number 12December 1992
leg appeared to lengthen, demonstrating a positive long-sitting test. This
supine long-sitting test is supposed to
suggest that the right innominate
bone is rotated posteriorly, whereas
the left innominate bone is rotated
anteriorly on the sacrum.l.11The twojoint hip flexor test, used to assess the
length of the hip flexor muscles,21 did
not show a difference in left or right
hip extension. The FABER test reproduced right-sided low back pain
(Fig. 1) only on testing the right side.
The FABER test was performed by
flexing the patient's hip to 90 degrees,
laterally rotating and abducting the
hip. A simultaneous posterior pressure was applied slowly to the medial
aspect of the involved knee and the
contralateral ASIS.6 Compression of
the sacroiliac joints, by applying pressure in a posterior and lateral direction over the supine patient's ASISs,
created identical right-sided low back
pain. Distraction of the sacroiliac
joints by applying a medially directed
pressure over the ASIS produced no
pain. Potter and Rothsteinz2obtained
reliable measurements for both sacroiliac joint compression and distraction, but all other tests of sacroiliac
joint dysfunction yielded unreliable
results.
Examination of leg lengths by visually
comparing the left and right soles of
the heels1 with the patient in the
prone position showed an apparently
short right leg. On flexing the knees
to 90 degrees, however, the apparently short right leg became longer.
This positive prone knee flexion test
suggested sacroiliac joint dysfunction.'
In view of the questionable reliability
of this assessment, however, the results are difficult to analyze. The
prone knee flexion test suggested the
presence of left anterior rotation of
the innominate bone with posterior
rotation of the right innominate
bone.'J1 When I applied posterior to
anterior pressure over the spinous
processes of all lumbar vertebrae and
pushed to the fullest extent of movement, the patient reported no pain.
There was 25 degrees of medial passive range of motion (PROM) and
65 degrees of lateral PROM. The
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the spine laterally flexed to the left. I
stood on the right side of the patient.
The patient's hands were clasped behind his neck. I threaded one arm
through the patient's clasped hands,
rotating the upper trunk toward me. I
then placed my free hand on the patient's ASIS that was furthest away from
me. I applied a posterior force to the
ASIS whlle the patient maintained full
upper trunk rotation (Fig. 4)."
Results
I
Figure 4.
The manipulative technique for the sacroiliac joint.
PROM of the left hip was 50 degrees
mediafly and 45 degrees laterally. This
method of measuring hip PROM has
been shown to yield reliable measurements.l6 Manual muscle tests
showed Normal muscle grade of the
right hip medial rotator muscles. The
hip medial rotator muscles were
tested as described by Kendall and
M~Creary.~'
Manual muscle tests
of both hamstring muscles, administered as described by Kendall
and McCreary, showed Normal grade
and were pain-free. Manual muscle
test grades in the Normal range, as
noted in my examination, are not
known to be reliable.
Assessment
My examination findings suggested to
me that the patient had a sacroiliac
joint dysfunction (Appendix).ll The
presence of pain around the PSIS
(Fig. I), tenderness to palpation medial to the PSIS, and the positive sacroiliac joint compression test all suggested sacroiliac joint dysfunction.18
Potter and RothsteinZ2found that
individual tests for sacroiliac joint
dysfunction yielded unreliable measurements, although it is unlikely that
a clinician would base an assessment
of a patient on one individual finding.
The use of a combination of tests and
the finding of four positive tests (ie,
uneven PSIS heights when sitting, a
positive standing flexion test, a positive supine long-sitting test, and a
positive prone knee flexion test),
however, suggest the presence of
sacroiliac joint dysfunction." The
reliability of measurements obtained
using a combination of tests for sacroiliac joint dysfunction has been shown
to be good, although the individual
tests yielded generally unreliable
measurements."
My initial goal was to attempt to reduce the patient's low back pain and
eliminate the apparent innominate
bone rotation. Elimination of any
innominate bone rotation is believed
to be necessary if an examination of
true leg length is to be performed.
Differences in leg length have been
suggested as a cause of sacroiliac joint
dysfuncti0n.l The presence of sacroiliac joint dysfunction can create an
apparent change in leg length, which
may confound the accurate assessment of true leg 1ength.l
Treatment Plan
I used a manipulative technique because the patient reported good results with manipulation performed
2 years previously by an osteopathic
physician. Briefly, the technique involved placing the patient supine with
After I performed the manipulative
technique, the patient reported that
his stiffness decreased when returning
from forward bending and that his
pain decreased during right sidebending. The four tests (ie, assessment of PSIS heights during sitting,
positive standing flexion test, positive
supine long-sitting test, and positive
prone knee flexion test) were repeated to determine whether innominate bone rotation was present. After
the manipulative technique, all four
tests showed no evidence of innominate bone rotation. In addition, the
patient reported no pain during the
sacroiliac joint compression test. After
performing the manipulation, I could
not detect the presence of anatomical
leg-length discrepancies by comparing
the heights of the PSISs while the
patient was sitting and then standing.
The reliability of measurements obtained with this technique, however,
has not been demonstrated.
I
!
After the manipulative technique, my
second goal was to attempt to restore
the patient's passive hip medial rotation by stretching. The patient was
instructed to stretch his right hip
lateral rotator muscles at least three to
four times a day within pain tolerance
(Fig. 5). He was instructed to lie
prone and have someone gently rotate his right hip medially until he felt
a slight stretch. The stretch was then
supposed to be held constant until he
no longer perceived a feeling of
stretching. This process was to be
repeated twice. The patient was instructed to stretch at least three times
a day. Finally, I advised him to quit
sitting and sleeping with the right hip
in extreme lateral rotation.
Physical Therapy/Volume 72, Number 12December 1992
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1
disability in his low back. His hip
PROM was improved, demonstrating
55 degrees of lateral rotation and
35 degrees of medial rotation on the
right. His trunk AROM remained
painless in all movements. About
3 months after the patient's initial
visit, he returned for an unrelated
problem. He reported that his low
back remained completely painless.
His right hip PROM now showed
50 degrees of lateral rotation and
45 degrees of medial rotation measured in the prone position. On examination, there remained no evidence of innominate bone rotation
suggesting sacroiliac joint dysfunction.
Discussion
Flgure 5. Stretching of the right hip
in the direction of medial rotation.
The patient reported during his next
visit, 2 days after the initial visit, that
he was much improved. An Oswestry
score showed significant improvement (a score of 16 versus the score
of 34 on day 1). His trunk AROM
remained painless in all directions.
Left and right straight-leg-raising tests
were painless at 9 5 degrees of hip
flexion with the knee extended. Hip
AROM and PROM were not measured
because in my experience I have
never found a change in hip AROM or
PROM in less than 1week. No further
treatment was given at this time because of his improvement. No symptoms o r signs indicative of sacroiliac
joint dysfunction were found on
reexamination.
The patient returned 1 week after the
initial visit for reevaluation. He reported that he had no further pain o r
stiffness in his lower back. Walking,
running, and moving from a sitting to
a standing position were all painless.
He also no longer noticed right-sided
low back stiffness upon arising in the
morning. An Oswestry questionnaire
now showed a score of 2, indicating
he had minimal perception of pain or
This case report demonstrates a possible relationship between asymmetrical hip rotation and sacroiliac joint
dysfunction. Postures the patient frequently assumed may have led to the
development of asymmetrical muscle
lengths in the hip rotator muscles.18
Habitual postures that place the hip in
extreme lateral rotation during sitting
and sleeping may have contributed to
the asymmetrical hip rotation by
shortening the hip lateral rotator
muscles and lengthening the medial
rotator muscles. Short lateral hip
rotator muscles may have contributed
to the innominate bone rotation that
is supposed to develop in sacroiliac
joint dysfun~tion.23~24
Some people believe that muscle
length o r strength imbalances may
cause sacroiliac joint dysfunction.1-3323-25 Muscles that attach to the
pelvis may influence sacroiliac joint
movement through their attachments.25 Presumably, shortened lateral
hip rotator muscles on thk right side
can posteriorly rotate the right innominate bone,2.23,24 resulting in a
concomitant anterior rotation of the
left innominate bone.11 Consequently,
a combination of short right hip lateral rotator muscles and long hip
medial rotator muscles may be responsible for creating antagonistic
innominate bone rotations and manifest as sacroiliac joint dy~function.~4
Data to support this hypothesis, however, d o not currently exist.
The initial treatment of the patient in
this case report was aimed at restoring innominate bone rotation and
decreasing the patient's pain. I have
found the manipulative technique
useful in instantly restoring the symmetry in innominate bones and in
decreasing the patient's complaints of
pain. I believe it is also important to
try to identify and correct factors that
may contribute to sacroiliac joint
dysfunction. The patient's habit of
maintaining extreme lateral rotation
of the hip while sitting and sleeping
may have contributed to his persistent
low back pain. I believe that assessment of hip muscle length asymmetries and habitual postures is important in the management of patients
who are believed to have a sacroiliac
joint component of low back pain.
Pain in and around the region of the
sacroiliac joint is common.26Although
this case report suggests that the sacroiliac joint may contribute to low
back pain, it does not necessarily
imply that abnormal sacroiliac joint
motion is the only source of low back
pain. McGi1126 suggests that pain
around the sacroiliac joint may be the
result of large stresses from the extensor muscles transmitted to the sacroiliac region. Further research is obviously necessary to understand the
existence and potential origin of sacroiliac joint pain.
I cannot deny that this patient may
have gotten better on his own without
treatment; however, the reduction in
episodes of low back pain gives some
support for this method of treatment.
A case report, however, cannot adequately assess what effect, if any,
asymmetrical hip rotation may have
on sacroiliac joint dysfunction o r on
low back pain. The limitations of a
single case report necessitate the
need for future controlled studies to
determine the relationship between
asymmetrical hip rotation and sacroiliac joint dysfunction.
This case report described a successful treatment of a patient who had
low back pain by manipulating the
72, Numberfrom
12December
1992
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References
Appendlx. Symptoms and Signs
Suggestive o f Sacroiliac Joint Dysfunction
Pain and tenderness located around the
PSISa (see Fig. 1)
Pain with walking
Pain on straight leg raising above
70 degrees on the painful side
Pain with the FABER test on the painful
side
Pain with pelvic compression
Finding of uneven PSIS when sitting
Positive standing flexion test
Positive supine long-sitting test
Positive prone knee flexion test
"PSIS=posterior superior iliac spine
sacroiliac joint, then restoring symmetrical hip rotation and eliminating
extreme unilaterally rotated hip postures. Presumably, the extreme laterally rotated hip postures contributed
to the asymmetrical hip AROM and
PROM and low back pain in this patient. Prevention of chronic extreme
lateral hip rotation in sitting and
sleeping, as well as restoring hip
rotation AROM and PROM, appeared
to eliminate this patient's recurrent
low back pain.
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Physical
/Volume 9,72,
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12December 1992
The Treatment of the Sacroiliac Joint Component to
Low Back Pain: A Case Report
Michael T Cibulka
PHYS THER. 1992; 72:917-922.
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