SI Joint Syndrome or Piriformis Syndrome or Gluteus Medius Syndrome

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The sacroiliac joint may be the most over diagnosed joint related to lower back pain.  The Sacroiliac joint or “SI” joint as it is known is the joint between your sacrum and your Ilium or pelvic bone.  The SI joint allows for transfer of weight between your upper and lower body.  Most researchers agree that only a small amount of motion occurs at the SI joint, perhaps 2-4 degrees at the most.  In order to have SI joint pain you would have had to suffer a sprain to the sacroiliac ligaments or possibly have arthritis from long term wear and tear….which would be unusual considering the limited 2-4 degrees of motion allowed by the SI joint (in order to have tear you have to have the wear…..without motion there is not much wear).

In my experience lumbar disc bulges, Piriformis syndrome and gluteus Medius syndrome are often misdiagnosed as SI joint dysfunction.  Here is the crux of the issue.  Muscles move bones.  Joints allow for the movement between the bones and dictate, based on their shape, what type of movement will be allowed.  Ligaments connect bones to one another and provide stability for the joints. Without ligaments to provide structural support all of our joints would be hypermobile and predispose us to various injuries.  This is why if you tear your ACL (anterior cruciate ligament) in your knee doctors want to surgically repair it because without it your knee will be “sloppy” and give out on you regularly.  The sacroiliac joint then, if sprained would mean you have ligament damage and a HYPERmobile sacroiliac joint.  Think about it.  This makes no sense as we have already established that due to the shape of the SI joints only 2-4 degrees of motion is allowed….how HYPERmobile could it be?  In addition, if the ligament is injured and the joint is HYPERmobile why are so many of the treatments therapists employ in an attempt to “improve” it increase range of motion (stretching) or mobilization such as in a chiropractic adjustment?  In my opinion these treatment would only serve to further the HYPERmobility and would be counter-productive.

Many patients diagnosed with SI joint dysfunction are known to have muscle spasms in their Gluteal (buttock) region.  The muscles found in this region are the Gluteus Maximus, Gluteus Medius, Gluteus Minimus, Piriformis, Obturator Internus and Externus and the Gemellus Superior and Inferior.  The Gluteus Medius and Minimus as well as the Piriformis, Obturator and Gemellus muscles are known to provide stability and support during walking and running. Few of us are anatomically symmetrical (maybe 25% of the population) and even fewer of us actually use our legs for the purpose of exercise (it is thought that 20% of less of the US population exercises and out of that even fewer walk or run for exercise).  For this reason it is common for me to see in those that run or walk and are not anatomically symmetrical pain in the muscles of the hip (Gluteus Medius, Minimus, Piriformis, Gemellus and Obturator muscles) due to asymmetric weight bearing and increased forces on the involved side due to their asymmetry and repetitive motion as in walking or running. Over time the muscle becomes hypoxic (not enough oxygen) and painful.  The pain is felt throughout the Gluteal region due to hyper-sensitive trigger points usually found in the Gluteus Medius or the Piriformis muscles.  These trigger points are not only hyper-sensitive but are painful due to the inability of the over-worked and strained muscle to release the spasm in it.

This is where and why people become “chronic” when they get diagnosed with SI joint dysfunction.  They go to their medical doctor who prescribes anti-inflammatory medications such as prescription Ibuprofen and orders an X-ray which shows…..you guessed it….nothing.  The anti-inflammatory medications either don’t help at all or only help a little.  If the patient pleads and persists they are then referred to physical therapy.  The physical therapist at this point is usually guilty of perpetuating the patient’s problem due to the inaccurate diagnosis by the MD.  Typical physical therapy treatments include stretching of the SI joint (why would you want to stretch a joint?). Strengthening of the hip muscles (Gluteal muscles, Piriformis, Gemellus, Obturator muscles) usually serves to aggravate the problem or some sort of misdirected massage that leaves the patient bruised and confused.  Now the patient visits their Chiropractor who has them come 2-3 times per week and attempts to adjust, manipulate, mobilize (choose you word for “crack” and insert here) their spine in an attempt to “get stuff moving” or to “align their SI joint”.  I have news for you.  If your SI joint which only is capable of moving 2-4 degrees is out of alignment then that means you have a sprained ligament which equals a HYPERmobile joint and adjusting a HYPERmobile joint is contraindicated……especially 2-3 times per week!  Time to stop going to the Chiroquacker!

How do you accurately diagnose and differentiate SI joint dysfunction from Piriformis Syndrome or Gluteus Medius Syndrome?

The most important way to differentiate SI joint dysfunction from Piriformis Syndrome or Gluteus Medius Syndrome is to LISTEN to the patient’s history and description of their symptoms.  Secondly a thorough orthopedic assessment should be performed.  These orthopedic tests are commonly taught worldwide in medical schools, chiropractic schools and physical therapy colleges.  These tests allow the doctor to differentiate where the pain is coming from by stressing various tissues and nerves.

Patrick Fabre’s Test

P. fabres test

 

 

May cause pain in the Sacroiliac Joint.  it is important to remember you are also stretching the adductors in this position and stressing the acetabular joint.

 

 

Nachlas test

nachlas test

 

May cause reproducible pain in the SI joint.  It is important to remember that you are also stretching the Quadricep in this position.

 

 

 

Trendelenbergs Test

gluteus-medius-trendelenburg-test

 

Weakness of the Gluteus Medius may cause pelvic instability due to the muscles iability to support during single leg stance

 

 

 

Gluteus Medius Trigger Point Pain Pattern

glute medius trig points

 

 

Gluteus Medius triggers points cause a painful butt

 

 

Piriformis Test

stretches the glute medius and piriformis

stretches the glute medius and piriformis

 

 

 

if stretching aggravates the area it could be the piriformis or gluteus medius

 

 

Piriformis Trigger Point Pain Pattern

pirformis trigger points

 

 

you can see from the picture why this condition can easily be confused as sciatica

 

 

How do you effectively treat Si joint dysfunction, Piriformis Syndrome or Gluteus Medius Syndrome?

Once a proper diagnosis is achieved an effective treatment plan is put in place that meets specific criteria.  It must be reasonable and practical, not worsen the patient’s condition and must result in resolution of the patient’s symptoms.  The first thing that is necessary is to remove the irritant.  If you are suffering from SI joint pain and/or Gluteal pain and you are continuously doing something or some activity that is either causing it or aggravating it will never get better!

Step 1: Remove the irritant(s)

The next most important thing to do as the doctor is to establish WHY the patient is suffering from the SI joint or Gluteal pain.  One patient may have SI joint pain due to trauma resulting in ligament laxity and HYPERmobility while another patient may be suffering from Gluteus Medius Syndrome due to overuse during accelerated marathon training or excessive hill repeats yet another may have Piriformis Syndrome due to an anatomical asymmetry such as a short leg.  These 3 patient examples would all be treated separately and distinctly.

if you don't remove the cause no therapy can work

if you don’t remove the cause no therapy can work

Step 2: Find the cause and remedy it.

Treatments for SI joint dysfunction, Gluteus Medius Syndrome and Piriformis Syndrome range from conservative to surgery.  Surgery should only be used in severe cases that do not respond to conservative measures.  Conservative treatments for SI joint dysfunction, Gluteus Medius Syndrome or Piriformis Syndrome include chiropractic adjustments, modalities such as ultrasound, traction, strengthening exercises and home exercises such as stretching and foam roller routines.  When the correct treatments are combined we find the effects to be magnified and are able to help many patients with SI joint and related injuries recover quickly.  Unfortunately many clinics ONLY provide one of the interventions causing the person to recover slowly or even worsen and progress to worsened state.

If you have SI Joint Dysfunction treatment should be:

Modalities to help heal the injured ligaments

can increase blood flow to ligaments severely lacking in blood

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can increase blood flow to ligaments severely lacking in blood

 

 

 

 

SI joint Stabilization Exercises to Promote Joint Stability

Si exercise

 

 

There are many exercises to promote joint stability……and then there are those that actually work.

 

 

Mobilization/Manipulation/Chiropractic Adjustments if your SI Joint is HYPOmobile (does not move enough) but this is CONTRAINDICATED if you are HYPERmobile as Chiropractic adjustments increase mobility.

gentle chiropractic adjustments align the spine

Do not adjust HYPERmobile joints

 

 

 

 

 

 

If you are HYPERmobile we will refer you for a PRP (Platelet Rich Plasma) injection.  This will stimulate healing of the damaged ligament which will then allow therapies that may have previously failed to work.

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By | 2017-05-08T17:00:29+00:00 April 28th, 2016|Uncategorized|Comments Off on SI Joint Syndrome or Piriformis Syndrome or Gluteus Medius Syndrome

About the Author:

Dr. Runco is a U.S. Navy and Gulf War Veteran. He began private practice in 2000 primarily treating and fixing running injuries. He has been a professor of Anatomy, Physiology, and Biomechanics at various colleges and continues to teach continuing education in the fields of rehabilitation, custom orthotics and athletic taping. He is also a member of the American College of Sports Medicine, National Strength and Conditioning Association and is a Certified Strength and Conditioning Specialist. He has completed over 15 Marathons in 15 states and has run 11 50 mile Ultramarathons.