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Sacro-iliac Joint Dysfunction and Low Back Pain:
Gentle Techniques for Structural Alignment
and Re-education
AAMT National Conference 2015
Presentation Overview
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Review the structures involved in SIJ dysfunction
Outline the principles of structural work from a positional release perspective
Learn basic release positions for the psoas, pelvis, lumbars and sacrum
Activate proprioceptive re-education of the pelvic girdle for SIJ balance
Learn client home exercises for maintaining postural changes and structural alignment
Symptoms and Consequences of SIJ Dysfunction
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Sciatic pain
SIJ pain
Pelvis rotation and leg length discrepancy
Low back pain
Hip socket pain or restricted movement
Pubic bone pain
Distorted sitting postures
Gait imbalances
Scoliosis/kyphosis
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Overview of the Bony Structures
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Partly synovial and partly syndesmosis (posterior sacrum to ilium – “ankle”-type)
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Sacral articular cartilage is hyaline cartilage and the iliac articular cartilage is fibrocartilage
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Sacral articular cartilage is 3 times thicker than iliac articular cartilage – 6 mm v 2 mm
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At birth surfaces are smooth and flat, developing uneven contour after puberty
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Early 20s the sacral articular surface becomes depressed and the iliac articular surface
becomes elevated
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Two parts of the SIJ: cranial portion – points upward and slightly backward; caudal portion –
points backward and slightly downward; angle of the articular surface – region between the
cranial and caudal portions
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SIJ makes an angle of 20 degrees
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Ligaments
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Downward force on the sacrum is resisted by the ligaments supporting the SIJ which in turns
stabilises the joints.
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Syndesmoses – interosseous or axial ligament which spans the gap between the sacrum and
the ilium (deep to the posterior sacroiliac ligament)
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Direct support from the posterior and anterior sacroiliac ligaments; indirect support from
the sacrospinous and sacrotuberous ligaments
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Also the iliolumbar ligaments from the TVPs of L4 and L5 to the iliac crest
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Pubic symphasis – fibrocartilage disc (4 mm thick) sandwiched between layers of hyaline
cartilage; contributes to the “clamping effect” of the SIJs
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Axes of Rotation
Malfunction on one side overloads the opposite side
Malfunction at the lumbosacral junction overloads SIJ
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Sacral Torsion
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Shock absorption – in response to impact loads such as with the heel strike with walking or running
Degeneration of SIJs will transfer the shock absorption to the lumbar vertebrae
Nutation of the pelvis – forward rotation of the sacrum about the SIJs resulting in the posterior
aspects of the ilia are drawn closer together and the ischial tuberosities move farther apart.
Counternutation of the pelvis – backward rotation of the sacrum about the SIJs resulting in the
posterior aspects of the ilia move farther apart and the ischial tuberosities are drawn closer
together.
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Lumbar nerves enervate the joint capsules of the SIJs
With unstable SIJs the normal interlocking of the articular surfaces can result in abnormal
interlocking and result in sacroiliitis
Anterior dysfunction of the SIJ – can happen when the torso is inclined forward and can be
unilateral or bilateral. The normal shock absorption function in impaired. The lumbar segments are
then overloaded and it creates low back pain. Women are particularly susceptible to anterior
dysfunction just prior to and during menstration.
Once anterior dysfunction has happened the likelihood that the sacrum on the ilium on the affected
joint is greatly increased.
Osteitis pubis – microtears in the disc and supporting ligaments in response to shearing forces
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Principles of Positional Release
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Structure governs function
Exaggeration of the preferred posture/preferred direction commonly the distortion
The body will release imbalances when it is in positions of comfort - no pain to release pain
Follow what the body is doing rather than forcing it
Use tender points to monitor the tissue for maximum relaxation or softening to identify the
release position
“Fine tune” the position by using gentle movements to stimulate the maximum state of
relaxation around the joint
Quality of Contact and Interaction
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Generally a gentle compression will stimulate and speed up the release within a joint or its
surrounding tissues
The most effective method is to do less to initiate the self-corrective reflex and to allow the
person to do more for themselves - “Less is more”
Non-investment in change - it is more important to notice what the outcome is rather than
to try to create a specific outcome
The body has many of the resources to balance itself - our role as Practitioner is to facilitate
these naturally occurring processes
Relaxed hand contact allows greater sensing capacity for the Practitioner
Techniques
Psoas
Imbalance Indicators
Femur Resistance to Internal Rotation
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Client is supine
Practitioner places hand just proximal and posterior to the ankle
Gently rotate the entire leg medially assessing for range of motion and ease of movement,
especially at the level of the hip socket
Resistance to internal rotation could be an indication of psoas restriction
Assess only one leg/hip at a time
Referred Pain Point
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Client is supine
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Assess for tenderness midway between the umbilicus and the ASIS
Tenderness or restriction here may be in indicator of psoas restriction
“C – Curve” Release
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Client is supine
Practitioner assists the client in laterally flexing (“side bending”) their torso towards the
affected side with client resting in that position
Practitioner then gently abducts and slightly laterally rotates the leg on the affected side
until the client’s leg reaches a position where it rests and relaxes naturally
Practitioner applies compression up the client’s leg towards the hip by placing the client’s
foot on the practitioner’s hip and then leaning slightly forward towards the client’s hip
At this point, if it is comfortable for the practitioner, gently grasp the client’s hand to
support the lateral movement
After observing the rebound or release, gently return the client to a neutral position and
recheck the imbalance indicators
Note: Another way to release the psoas can be accomplished with the Lumbar 2 (L2) positional
release.
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Lumbars
Imbalance Indicators
Imbalances in the lumbars can be indicated by referred pain points located bilaterally on the pelvis.
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L1 – Point medial to the ASIS
L2 – Point midway between the ASIS and the pubic bone and either superior or inferior to
the inguinal ligament
L3 – Point on the lateral margin of the tensor fascia lata muscle as it crosses the gluteus
medius muscle
L4 –Point in the mid buttock at the centre of the gluteus maximus muscle
L5 – Point medial to the PSIS
Release Positions for L1 – 2
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Client is supine
Client bends knees and places feet on the table (if that causes discomfort the client can also
bring up only one knee of that is more comfortable)
Practitioner monitors the point of imbalance, grasps the client’s lower legs and supports the
legs against the practitioner’s shoulder
Practitioner steps forward towards the head of the table drawing the clients legs superiorly
and resting supported over the client’s hips
Practitioner allows the client’s legs to drop laterally until the point of imbalance is maximally
softened
After the release, the practitioner replaces the client’s legs onto the table and reassesses the
point
Note: It is possible to release all of the lumbar points using the release position for L1-2.
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Release Positions for L3 – 4
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Client is prone
Practitioner grasps the client’s hip opposite to the affected side
Practitioner then draws the client’s hip posteriorly and then folds towards the midline
towards the indicator point until the point is maximally softened
After the release, the practitioner replaces the client’s hip on the table and reassesses the
point
Release Positions for L5
Option One:
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Client is prone
Client slides diagonally on the table allowing the leg of the affected side to hang off the side
of the table
Practitioner stands next to the table and supports the client’s leg by resting the client’s shin
on the practitioner’s thigh
Alternatively, the practitioner can use a chair and support the client’s leg on the
practitioner’s thigh
Use hip flexion, extension, abduction and adduction to find the position of the leg that
maximally softens the point of imbalance
After the release, assist the client by replacing their leg on the table and reassess the point
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Option Two:
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Client is prone
Client crosses the leg of the non-affected side across the back of the leg of the affected side
Practitioner gently grasps the client’s crossed leg proximal and anterior to the knee and
gently draws the leg across the midline until the point of imbalance has maximally softened
After the release, the practitioner replaces the client’s leg on the table and reassesses the
point
Ilium Rotation
Imbalance Indicators
Leg Length
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Client supine
Assess apparent leg length differences by bringing the client’s feet together and assessing
discrepancies in leg length at the ankle
Client prone
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Assess the Sacro-iliac joint imbalance point located 2.5 cm (1 inch) lateral and 2 cm (¾ inch)
inferior to the PSIS
The SI Joint indicator point will help in assessing which side is likely to be experiencing the
imbalance
Posterior rotation of the pelvis at the ilium creates an apparent Short Leg
Anterior rotation of the pelvis at the ilium creates an apparent Long Leg
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Posterior Rotation Release (Apparent Short Leg)
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Client is prone or side-lying
Client abducts and flexes the hip of the affected side – “frogging” the leg
Practitioner stands on the opposite side and exaggerates the posterior rotation by drawing
the ASIS posteriorly with one hand whilst gently pressing the ischium of the same innomiate
anteriorly creating a gentle twist of the ilium
After the rebound or release, have the client straighten their leg and return to a neutral
position as the practitioner reassess the imbalance indicator
Anterior Rotation Release (Apparent Long Leg)
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Client is prone or side-lying
Practitioner stands next to the affected side and flexes the client’s knee placing their hand
proximal and anterior to the knee
Practitioner gently draws the client’s leg posteriorly (hip extension) whilst pressing the
client’s ilium anteriorly creating a twist of the ilium
After the rebound or release, replace the client’s leg on the table and reassess the imbalance
indicator
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Isometric for Ilium Rotation
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Client is supine
For anterior rotation (long leg): flex client's leg and move it medially. Have client press leg
laterally. Follow through.
For posterior rotation (short leg): flex client's leg and move it laterally. Have client press leg
medially. Follow through.
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Diagonal Ilium Rocking
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Client is prone.
Place one hand on the client’s ilium just above the PSIS and the other hand on the opposite
ischium. Initiate a “seesaw” movement following the body’s timing until the two sides
balance.
Sacrum
Imbalance Indicators
Tension or points of tenderness or restriction on the sacrum and especially along the sacral margins
General Release
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Client is prone
Practitioner assesses movement ease or preference in the following directions:
superior/inferior; lateral (side-to-side); rotation clockwise/anticlockwise
With each movement preference the practitioner gently holds and compresses the sacrum
in each position until a rebound or release.
It is also possible to “stack” all of the preferences into one release.
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Tender Points on the Sacral Margin
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Client is prone
Practitioner monitors the imbalance point and then draws the ilium and/or femur of the
same side as the point towards the point until the point is maximally softened focusing on
the pulls of the ligaments
After the release, the practitioner replaces the hip on the table and reassesses the point
Piriformis
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With client prone, check for tightness in the piriformis.
Abduct their leg and rotate their leg medially.
Have client rotate their leg externally with an isometric.
Follow through.
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Femur Rotation
Imbalance Indicator
Exaggerated medial or lateral rotation of the femur at the level of the acetabulum and may be
related to lateral or medial foot orientation as well as restriction in rotational movement at the hip.
Positional Release
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Client is supine
Practitioner assesses movement preference by rotation of the femur medially and laterally
asking for the client’s experience of what feels more comfortable or habitual
Practitioner gently exaggerates the rotation preference and compresses the femur towards
the hip
After the release, the practitioner returns the leg to neutral and reassesses the preference
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Note: It is best to include the seated isometric/isotonic to facilitate greater proprioceptive reeducation
Seated Isometric/Isotonic
Internal Femur Rotation
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Client seated
Client crosses affected leg over the other leg—either across the thigh or the shin
Practitioner draws the affected leg towards the midline whilst bringing the clients opposite
shoulder also towards the midline
Practitioner holds the client in this position whilst the client attempts to gently push their leg
and shoulder away from each other (using on 10-20 per cent of their strength)
After approximately 7 – 10 seconds the practitioner tells the client to relax and the
practitioner follows through with the movement by moving the client’s leg and shoulder
away from each other
Repeat the isometric 2-3 times
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External Femur Rotation
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Client Seated
Client crosses affected leg over the other leg—either across the thigh or the shin
Practitioner gently presses the clients leg laterally and holds the clients opposite shoulder as
the client is seated upright
Client then attempts to bring their leg and shoulder together whilst the practitioner holds
the client in place (10 – 20 percent of the client’s strength)
After approximately 7 – 10 seconds the practitioner tells the client to relax and the
practitioner follows through with the movement by bringing the client’s leg and shoulder
towards each other
Repeat the isometric 2-3 times
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Pelvic Flare
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Client is supine.
Assess for pelvic flaring by placing your hands on both sides of the client’s pelvis at the level
of the top of the ilia and press them directly towards each other.
Then place your hands on both of the greater trochanters of the femurs and press again
directly towards the mid line. Determine the preferred direction.
Place one knee on the table against either the ilium or the trochanter and reaches across the
client toward the opposite ilium or trochanter and compresses bilaterally toward the mid
line.
The practitioner can also isolate the movement by having the client align their body along
the edge of the table whilst the practitioner uses his or her hip against the client’s hip and
compresses the opposite hip toward the midline.
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Proprioceptive Re-education Exercises
Sitting on Sit Bones
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Client sits on a firm surface and slowly rotates the pelvis forwards and backwards finding the
position in which the ischial tuberosities (sit bones) are pointing directly downward.
The lumbar spine should be relaxed during this exercise with all of the movement coming
from the pelvis.
Moving the Hips and the Breath
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Client is supine.
Client bends knees up and places feet shoulder width apart on the table.
Client begins breathing deeply into their abdomen allowing the exhalation to be long, slow
and relaxed.
Client begins to visualise the breath moving out through the sacrum during the exhale.
After several breaths, the client should begin to add weight to the bottom of their feet
during the exhalation and then release the pressure on their feet during the inhalation.
Client should feel a lengthening of the back muscles.
References
Alter, Michael (1996) Science of Flexibility, 2nd edition. Human Kinetics Publishing, Champaign IL
Chaitow, Leon (2007) Positional Release Techniques, 3rd edition. Churchill Livingstone Elsevier,
London
Fogel, Alan (2009) Body Sense: The Science and Practice of Embodied Self-Awareness. WW Norton,
New York, NY
Fogel, Alan (2009) The Psychophysiology of Self-Awareness: Rediscovering the Lost Art of Body
Sense. WW Norton, New York NY
Hesch, Jerry (2011) “Sacral Torsion About an Oblique Axis”, in Erik Dalton, Dynamic Body: Exploring
Form Expanding Function
Jones, Lawrence (1981) Strain and Counterstrain. American Academy of Osteopathy, Indianapolis IN
Kain, Kathy with Jim Berns (1997) Ortho-Bionomy: A Practical Manual. North Atlantic Books,
Berkeley CA
Overmyer, Luann (2009) Ortho-Bionomy: A Pathe to Self-Care. North Atlantic Books, Berkeley CA
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Richard, Raymond (1986) Osteopathic Lesions of the Sacrum: Physio-pathology and Correction
Techniques. Thorsons Publishers Ltd.
Schwind, Peter (2003) Fascial and Membrane Technique: A manual for comprehensive treatment of
the connective tissue system. Churchill Livingstone Elsevier.
Still, A T. (1910) Osteopathy: Research and Practice. Reprinted 1992, Eastland Press, Seattle WA
Sutherland, William (1990) Teachings in the Science of Osteopathy. Sutherland Cranial Teaching
Foundation.
Watkins, James (2010) Structure and Function of the Musculoskeletal System, 2nd edition. Human
Kinetics Publishing, Champaign IL
Resources
For further training opportunities visit www.brucestark.com.au to get course offerings, class
descriptions and further resources for learning Ortho-Bionomy and structural bodywork.
www.facebook.com/BruceStarkOrthoBionomy
@brucestark
Detailed information on Practitioner Training Programmes can be found at:
Ortho-Bionomy Australia Ltd
www.ortho-bionomy.org.au
Society of Ortho-Bionomy International
www.ortho-bionomy.org
Photographer: Chris Griffith Model: Hank Adam
Thank you Chris and Hank for your help!
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