Editor's Note: Part 1 of this article appeared in the March issue.
When an SI joint is fixed, the patient will typically have tenderness in the joint, but the degree of tenderness will vary over the course of the joint. The next task is to identify a clearly demarcated locus or point of tenderness using digital pressure over the PSIS-sacrum interspace.6-7 The tender point is often located at the transition between the lower, syndesmotic portion of the joint and the upper, synovial portion, and tends to coincide with the focus of fixation within the joint.
Palpating for Point Tenderness
To locate the tender point, apply a gentle, but firm pressure through the joint plane of the PSIS-sacrum interspace. Note both verbal and non-verbal indications from the patient that the contact point is tender. Be sure to apply pressure over the entire course of the joint, even though the greatest point tenderness is likely to occur at the junction between the synovial and syndesmotic portions of the SIJ.
One possible explanation for tenderness discovered superficial to intra-articular adhesions may be the body's response to stresses, particularly overuse of a joint. An inflammatory response at the site of injury includes the classic signs, such as swelling and altered motion, as well as fibroblastic responses within the fascial planes.
The result is deposition of collagenous and other proteinaceous materials bridging between surfaces that normally glide over each other. Consequently, pressure applied through the plane of the restricted tissue interface produces irritation of the adhesion, eliciting a nociceptive response.
Correcting the Fixation
The immediate goal when correcting the sacroiliac fixation is to break up adhesions in the joint interspace. By eliminating or reducing adhesion, the joint is freed to reset itself, thereby restoring ROM and activity potential, and abating symptoms.
Intra-articular adhesion tends to occur at the transition point between the lower syndesmotic portion of the joint and the upper synovial portion. Therefore, a thrust through the plane line of the joint space at the level of the fixation is most effective.
To locate the optimal segmental contact point, palpate with digital pressure firmly along the medial border of the PSIS. Palpate along the entire PSIS-sacrum interspace using moderate pressure through the joint plane. Palpation typically reveals a tender point along the medial border of the PSIS, and this point appears to coincide with the posterior aspect of the adhesion.
Like any adhesion between tissues that normally move smoothly relative to each other, distortion or pressure through the immobilized tissues produces discomfort or pain. Therefore, the tender point may resemble a trigger point.
The correction is applied directly at and through the tender spot revealed by digital pressure.7-9 Position your hand or the adjusting instrument directly on the tender point. The line of drive is posterior-to-anterior (P-A) and medial-to-lateral (M-L) through the joint space.
Note: The correction here is directed through the soft-tissue adhesion of the joint space and is not intended to consider traditional notions of sacroiliac joint misalignment. Such misalignments could include PI, AS, EX and IN ilium, and posterior rotation of the sacrum.
Post-Checking the Correction
Following correction of the sacroiliac joint fixation, test by repeating the SI fluid motion maneuver [described in Pt. 1]. If fluid motion results in lengthening of the leg only on the side corrected, the fixation has been removed. Similarly, digital pressure over the segmental contact point may elicit a reduced pain response. However, it is probably best to wait until the patient's next visit to assess the pain response properly.
References
6. Herbst RW. Gonstead Chiropractic Science & Art. Mt Horeb, WI: Sci-Chi Publications, 1974.
7. Colloca CJ. "Neuromechanical Innovations: The Neuromechanical System." Continuing education, New York College of Chiropractic, Chicago, October 2008.
8. Savoie S. "PulStar Level I & II Seminar." Continuing education, Pittsburgh, March 2012.
9. Fuhr AW. "Activator Methods Chiropractic Technique." Continuing education, Chicago, April 2012.
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