Paper of the month September 2023

Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain.

Spine (Phila Pa 1976). 1998 May 1;23(9):1009-15.

Cibulka MT, Sinacore DR, Cromer GS, Delitto A.

Michael T. Cibulka PT in the US send SIMEG office e-mail regarding hip-sacroiliac relationship in response to this ICSJS2023 topic “Hip-Sacroiliac syndrome”, because he had many researches about this. He sent me his papers and I enjoyed reading them.

This paper reported that patients with SIJ dysfunction often show posteriorly rotated innominate and limited range of hip internal rotation on the affected side.

I would like to introduce our Q and A regarding this paper.

Dear Prof. Cibulka,

First, I enjoyed reading your paper “Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain”. It is very interesting.

I have a few questions.

Q1. Ｔhe posteriorly rotated innominate side is the side of the SIJ dysfunction? Or is it not related to the symptomatic side?

A1. I see pain much more often on the side that is posteriorly than anteriorly tilted, about 75% are posteriorly and 25% are anteriorly.

Q2, When the innominate bone is posteriorly tilt, the sacrum is relatively nutation position, and internal rotation of the hip causes the innominate bone to become inflare and the posterior sacroiliac ligament to be overstretched, resulting in pain?

A2. Not sure about that, I teach the sacrum is “stuck” between the innominate bones. Mechanically the sacrum is at the “whim” or “controlled” by the left and right innominate bones, it moves are dictated by the 2 innominate bones.

Q3. At this ICSJS 2023, I will report patients with severe SIJ dysfunction/pain secondary to FAI. With FAI, internal rotation of the hip is structurally limited and when there is a hip labral injury, it will cause groin pain. Does this condition continue to cause some derangement of the sacroiliac joint, or does it directly force the ilium to tilt posterior and/or to inflare, making the sacroiliac joint more vulnerable to derangement? How do you think the limitation of internal rotation of the hip is related to sacroiliac joint dysfunction?

A3. I will attach a paper I did on that subject.

Cibulka MT. Sacroiliac joint dysfunction as a reason for the development of acetabular retroversion: a new theory. Physiother Theory Pract. 2014 May;30(4):249-53.

• In this paper, he speculates that an outward or backward rotation of the innominate bone due to the movement of the sacroiliac joint part could cause acetabular retroversion. Acetabular retroversion is one of the risk factors for FAI. In my opinion, acetabular retroversion evaluated by CT seems to congenital dysplasia rather than the results of SIJ dysfunction because the SIJ can only slight move, but his hypothesis is interesting.

Q4. If the movement of the right and left ilium through the pubic symphysis is coordinated, is there less stress on the ipsilateral sacroiliac joint even if the internal rotation of the hip is limited due to FAI or muscle contraction? If so, what is the ideal condition of the contralateral ilium?

A4. Not sure what the question is, I discovered years ago that if one innominate anterior tilt the other must posterior tilt, thus movement also naturally develops during gait when one hip flexes the other extends. But in SIJ dysfunction it remains in that antagonistic position.

Cibulka MT, Morr B, Wedel J, Bohr Z, Jones G, Herman C, Strube MJ. CHANGES IN PELVIC TILT DURING THREE DIFFERENT RECIPROCAL STANCE POSITIONS IN PATIENTS WITH SACROILIAC JOINT REGIONAL PAIN. Int J Sports Phys Ther. 2019 Dec;14(6):967-977.

• This paper reveals that patients with SIJ dysfunction did not exhibit antagonistic innominate bone position that they should exhibit in an asymmetrical stance position. I don't know how severely patients with sacroiliac joint dysfunction were involved, but it should be one of the important findings.
• I also read his other case report to understand his way of thinking.
  Cibulka MT. The treatment of the sacroiliac joint component to low back pain: a case report. Phys Ther. 1992 Dec;72(12):917-22.
  Cibulka MT. Understanding sacroiliac joint movement as a guide to the management of a patient with unilateral low back pain. Man Ther. 2002 Nov;7(4):215-21.

Q5. In your rich professional career, have you ever seen patients with severe SIJ dysfunction/pain who needed to undergo SIJ fusion surgery so far?

A5. Clinically palpating the pelvis before and after manipulating the SIJ, observation and mine and other studies suggest an individual SIJ moves more 1-2 degrees. Why would fusion work if only 1 degree? Also, the SIJ is a synovial joint it has to move for cartilage nutrition.

Summary of my impression after having a discussion

I respect his many amounts of works and would like to learn further physical assessment techniques from him. The type of SIJ pathology may be slightly different between patients that we surgeons see and the patients that PTs see on a daily basis. In addition, although PTs are not able to make a definitive diagnosis through diagnostic injections, it would be better to construct a discussion of pathology based on diagnosing the source of pain through diagnostic injections. That is why we need to invite PTs into SIMEG, and we would like to share surgeons’ view with PTs here.

Daisuke Kurosawa