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Anatomy

Before opening the Pandora’s box that is the sacroiliac joint, lets start with the basics. What is a joint? A joint is the space between 2 bones. If you think about the hip joint, the two bones involved are the thigh bone (femur) and the pelvis. In this example the shape of the joint (a ball and socket) allows movement to occur in a big three dimensional circle and any combination of movement within.

The sacroiliac joint is a slightly different beast and to understand it we need to first look at the pelvis. The pelvis is made up of two halves,each half made up of 3 fused bones called the ilium, ischium and pubis. The front of the 2 pelvic bones are joined together at the pubic symphysis by strong ligaments (if you’ve ever been pregnant you might have cursed this joint) and at the back we have the junction that joins the sacrum at the bottom of the spine into the pelvis – the infamous sacroiliac joints.

What are the roles of the sacroiliac joints

The roles of the sacroiliac joints are to channel the force of the ground coming up through our legs and the weight of our body coming down through our spine, as well as to stabilise the junction between the pelvis and spine. The weight of our upper body and whatever we happen to be carrying passes down the spine until it comes to the junction of the sacroiliac joints where it now has the option of being shared, via the pelvis, down our 2 legs. The sacroiliac joints transmit this force and dampens it on the way through like a pair of mini shock absorbers. This journey can also be reversed as seen when our foot hits the ground and force is passed up.

How do they it do it?

For these joints to do their job effectively they need incredible strength, and this begins with the architecture of the bones themselves. The 2 wings of the ilia create a beautiful funnel into which the wedge shaped sacrum nestles snuggly, while the rough joint surface of the bones enable them to lock into place like the cogs of a clock. A motor way of ligaments and muscles then surround the joints to fortify their strength during the critical moments of movement when they are exposed to the most load. There has been much wonderful work recently that has looked at how muscles are set up to work as fascial slings, enabling muscular contraction to create force closure and thus stability. We will look at some  of these patterns in the following vlog.

So do the sacroiliac joints move?

If you ever want to see fireworks outside of Guy Fawkes night, drop this question into a room full of therapists, light the touch paper and watch from a safe distance.

In a nutshell the answer is yes. There is no way near the same range of motion as a hip joint and as we age this movement is reported to become even less (until in some it can eventually even fuse) however without it we have bit of a problem. To figure out why the sacroiliac joints must move we need to go back to the anatomy of the pelvis and realise how it has evolved to function more efficiently. If our pelvis did not need to move it would be infinitely stronger if it was made up of one whole bone instead of two halves with a pubic symphysis at the front and a sacrum wedged between the two ilia. To understand why it is as it is, I want you to stand up and place your fingers just under the 2 knobbly bits on the front of your hips called the ASISs (anterior superior iliac spines of the pelvis) and cup the rest of the pelvis in a c-shape with your palms. With your hands in place now go for a little walk around the room and notice how these bones start to rock up and down with each step you take. Now repeat the walk and try to do so without letting the pelvis move at all. You should have found the latter near impossible (unless you were wearing a very tight pencil skirt) and instead noticed that your pelvis nods in opposition as your pelvic ring rotates, drops and hikes in response to the pull of your lower limbs as you move. If your pelvis was in fact solid it would have to shatter with each step you took!

The problem we face is that because the motion is so small and we can have both too much or not enough of it, we need an assessment that allows us to know when and where to start treating …

…and with that little teaser I will leave you on the edge of your seat until the next functional assessment video.

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(P.S. latin words and anatomical names have been spared in the name of understanding all this stuff!)

The spinal column

The spinal column is made up of a series of bones (called vertebrae) all of which have a slightly different shapes and functions. These vertebrae all stack up to form the cervical spine (neck), the thoracic spine (mid back), the lumbar spine (lower back) and the coccyx and sacrum.  A well functioning spine should move with fluidity and ease enabling  us to walk, sit and dance (apart from my brother who could have a spine like a slinky and still dance like he has 3 left feet).

Each vertebrae is made of a dense bone outer shell with a lighter more honeycomb textured inner shell (malteser any one?) This structure allows our bones not only to be strong but also light, with ability to absorb force if we were to jump up and down or run. Each vertebrae is made up of a bony ‘body’ behind which you can find a hole called a foramen. When you stack all these vertebrae on top of each other the holes line up and become the spinal  canal through which the spinal cord runs .

The spinal cord

The spinal cord ferries information from our peripheries to our brain and then returns information back from the brain telling all the various areas of the body how to react. The nerve ‘tributaries’ that carry this information are called spinal nerves and they wind their way back from all round our body  and up through holes at the side of the vertebrae where they  join the spinal cord. The information itself is detected by receptors that are attached to the spinal nerves and are scattered everywhere from the skin’s surface to inside blood vessels and organs. These receptors detect information such as temperature, pain, vibration, stretch and even tickle and itch. When you witness a dog pushing its side into you as you give it a good scratch you are seeing this relay of itch information to the brain which results in a messaged being sent back “go on muscles lean into it and enjoy yourself!”

Discs

In order to allow the spinal bones to move on each other and to absorb force, they are separated by a series of ‘rubber washers’ called discs. Each disc is made up of a fluid filled sac called a nucleus and a strong fibrous outer band called the annulus which covers it and glues it to the vertebrae above and below.

Interesting fact

These discs fill with water every night as we lie down making us a little taller when we first get up in the morning. This is why people with back pain are often advised against strenuous exercise or stretching first thing in the morning as the discs are already taught.

Disc ‘bulge’

When we have a disc ‘bulge’ the nucleus starts to protrude through a tear in the tough annulus coating and can eventually reach through into the spinal canal where it can press on the spinal nerves. When these nerves are pressed upon they create a predictable pattern of weakness, lack of sensation and pins and needles, very much like a hose which is kinked and unable to transport water. When this happens in the lower back it can press on the tributaries that make up the sciatic nerve, creating that familiar pattern of ‘sciatica’ that can refer all the way down into the feet.

Here is a nice little you tube animation which demonstrates what happens when you have a a disc issue.
https://youtu.be/33LsxW-Zq0s

Ligaments

Ligaments are like little straps that attach bones to other bones. The vertebrae are connected by capsules and ligaments which then help stabilise our bony spinal column. When these ligaments are continuously stretched (think bad sitting posture or a compensation around another injury such as an ankle sprain) then these ligaments can become painful and lax. When ligaments experience a gentle stretch they can feed back information telling the brain which muscles need to work, but over stretch them and they become unhappy. A lot of what we do in clinic is to work out why these ligaments keep getting stretched, then we use hands on techniques and movement to straighten everything up and allow the body to find its centre.

Muscles

Muscles attach all the way up the spine at various different depths and, very much like ligaments, need to experience being loaded as well being unloaded.  If they are chronically stretched (for example if someone has their work desk set up so they are always rotated to one side) the stretched muscles will start to become painful and prone to tearing, while the shortened muscles will become congested. By finding a more balanced resting posture we can then remove the trigger to tissue pain and allow the body to do what it does best and start to heal.

Conclusion

So that was a quick whistle stop tour of getting to know your back anatomy. Once you know what is lurking around in that unknown area between your head and your pelvis, then things becomes a whole lot less scary. As a therapist all we do is find out the trigger that keeps causing things to be painful and remove it for a while while your body naturally gets better. Add a dash of movement to synchronise bones, muscles, ligaments and  nerves to coexist in harmony and we have our selves a treatment plan.

I hope this cleared things up a little bit and allowed you to picture what is going on back there. If you know any one who might benefit from this little guided tour, please feel free to share.

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