JOURNEY 6 – SIJ PROBLEMS IN TRIATHLETES: A PAIN IN THE BUTT

For this edition of Journey we have had a chat to Justin McEvoy, leading physiotherapist and co-director of Physiohealth about the common causes, signs and symptoms, and anatomy of Sacroiliac joint pain (SIJ Pain). Some of you may be aware of the nature and occurrence of SIJ pain caused by running. Some may have experienced this condition first hand. Some of you may never have heard of it. Whatever the case may be the following article will provide you with an oversight to the injury; including treatment, preventative measures and extra considerations.

Anatomy

The Sacro-iliac joints are weight bearing synovial joints between the Ilium and Sacrum. These joints are held together by very thick and strong ligaments, and the joint is stepped so that it interlocks into position. The Sacro-iliac Joints support the spine at its base and therefore absorbs the weight and jarring of weightbearing activities such as running and jumping. Owing to it being a synovial joint it also means that the joint responds to overloading with initially an acute synovitis (sacroiliitis) and can develop into a chronic synovitis and effusion, much like other weight bearing joints such as the ankle, knee and hip.

Causes

SIJ pain may occur from excessive forces being applied to the region of sacroiliac joint. This can be from bending, sitting, lifting or twisting movements of the spine, or, from weight bearing forces associated with running and jumping. Injury to the sacroiliac joint may occur traumatically or due to repetitive or prolonged forces over time.

Such pain is commonly unilateral and one common cause is uneven weight bearing in a running athlete. This can be caused by training with a painful lower limb (running with even a slight limp), training on a running track in one direction, having either a real or functional leg length discrepancy or stiff and painful facet joints in the lumbar spine. Other causes are related to poor biomechanics in the foot and commonly ineffective core.

Swimmers can also complain of sacroiliac pain and inflammation. All 4 strokes hold the sacroiliac joint in extension (compression of the joint surfaces bilaterally.)

Justin also explained that tight structures such as Gluteus medius and piriformis are usually secondary to the original cause. Trochanteric bursitis can also be a secondary pathology to sacroiliac joint injury.

Listed below is a summary of some other contributing factors:

• Muscle imbalances

• Poor posture

• Lumbar spine stiffness

• A sedentary lifestyle

• Inappropriate lifting technique

• Being overweight

• A lifestyle involving large amounts of sitting, bending or lifting

• Pregnancy (the associated pelvic girdle changes may also contribute to the development of sacroiliac joint pain)

Signs and Symptoms

One sided low back pain around the top of the buttock is usually experienced by patients with this condition. Symptoms often refer into the lower buttock, groin and thigh. Pain is generally exacerbated during activities involving lower back and hip movements, but it is rare that pain is felt on both sides of the lower back.

Pain will be felt in the region of the lower back and hip even when partaking in simple everyday activities such as putting on shoes and socks or walking up stairs. Tenderness can also be felt when palpating the SIJ, and pelvic asymmetry may result from the condition due to the joint dysfunction.

Diagnosis

Justin explains that assessment is straight forward and can be discerned via the athlete’s history, palpation and standing on the ipsilateral leg. It is important to ascertain the mechanism of injury as this will assist in the treatment and resolution.

Treatment

An acutely inflamed SIJ can be resolved quickly through cessation of the aggravating activity, manipulation and activation of the abdominal musculature. Return to the aggravating activity (i.e., running) should be gradual with continued manipulation and core exercise.

Often the more chronic injuries require more complex treatment modalities such as functional restoration of leg length, activation exercise for core during running, and foot biomechanical adjustment via orthoses, and or drills. Commonly cortisone injection and NSAIDs are also required as the design of the joint in weight bearing is not conducive to breaking the inflammatory cycle.

Recovery time is largely dependent on the length and severity of the injury, and how quickly treatment begins.

Other basic Physiotherapy:

• Soft tissue massage

• Mobilization and manipulation

• Taping and bracing

• Correction of any leg length discrepancy

• Education

• Biomechanical correction

• Pilates and hydrotherapy

• Exercises to improve flexibility, strength, posture and core stability

• A gradual return to training

Prevention

Prevention is the best treatment and this is achieved by having maintenance treatments with your “Sports Physiotherapist” who will not allow a functional leg length develop, will release and mobilize the lumbar and sacro-iliac joints, as well as release glutes, hip flexors and other surrounding musculature. Your physio should be able to help you manage your training program and identify any signs and symptoms of the condition. Athletes are encouraged to maintain posture and core conditioning, as well as stretching the region thoroughly.

Extra Considerations for Triathletes

Running and swimming are both performed in lumbar extension so the SIJ can very easily be irritated and the less stable an athlete’s core is the more likely the SIJ can be inflamed/ irritated. The stronger the core, the less force will develop through the SIJ. Therefore abdominal flexion exercises such as crunches and other core exercise will assist the athlete reduce the probability of SIJ injury.

It is encouraged that any track running be uni directional where possible and athletes avoid spending too long running in one direction.

Also tight Lumbar extensors (lower back, glutes, hamstrings etc) will create increased force through the SIJ, so stretches of the lumbar extensors should also be part of the treatment exercise program. Cycling can be performed while the triathlete has SIJ pain as it is performed in flexion.

Thank You to Justin McEvoy from Physiohealth, Footscray for providing us with an insight to this common condition. Justin is Co-Director of Physiohealth and has been a physiotherapist for over 16 years. Justin has achieved a Masters degree in his studies after completing a Post Graduate qualification in Sports Physiotherapy. He was also one of the very few who first qualified as a ‘Sports Physiotherapist’ in Australia.

Acknowledgements

Justin McEoy: McEoy, J. 2011. [Personal Communication]. 19th July.

PhysioAdisor: Sacroilliac Joint Dysfunction 2008, PhysioAdvisor.com. viewed 18th July 2011, http://www.physioadvisor.com.au/8388150/sacroiliac-joint-dysfunction-sacroiliac-pain-s.htm