The Central Source of the Problem: The Interosseous Ligament
Within the weight-bearing portion of the SIJ is the interosseous ligament, which contains a blood vessel, connective and fatty tissue. This ligament is not a single continuous band. Rather, it is composed of many individual bands that go between the sacrum and ilium. When sprained, these interosseous ligament bands do not tear. Instead, they pull away from their insertion into either the sacrum or ilium; this allows the joint to separate slightly. Fluid from the surrounding tissues, as well as from blood vessels within the joint, infiltrates the space between the sacrum and ilium and creates swelling, inflammation, and pain. Here is the key point: the fluid within the space keeps the joint surfaces apart, preventing the re-integration of the ligament into the bone.
It is reasonable to assume that the internal pressure caused by the swelling pushes out on the joint surfaces, stretching the ligaments. Nerves within the ligaments respond by activating the ligamento-muscular reflex which, in turn, causes protective muscle contraction. The internal pressure of the swelling, pushing out, is countered by the external muscular compression, pushing in, resulting in the body's best attempt at stability.
However, over time, the muscle contraction becomes chronic, causing many problems throughout the musculoskeletal system. As long as the excess fluid remains in the joint space, the ligaments cannot re-integrate into the joint surfaces and the joint cannot heal. And muscular contraction/inhibition patterns will persist. To heal the joint, the surfaces must be brought together so that the ligaments can re-integrate into the joint surfaces and heal.
Comparison to Other Treatments
A comparison between the category 2 blocking procedure and the most prevalent methods for treating the sacroiliac lesion, chiropractic manipulation and muscle strengthening is explained below.
Although very effective in aligning the joint and removing stress, a quick short thrust, as done by chiropractors, is not effective enough to remove all the fluid from the SI joint space. However, it will usually give considerable relief because it can take a lot of stress off the injured ligaments. With respect to the removal of the excess fluid within the SIJ, though, I compare it to stepping on a water balloon; most of the fluid will be removed but some will remain to keep the surfaces apart, so the ligaments will not be able to reintegrate into the joint surfaces. Eventually, more fluid will re-enter the joint and the lesion will recur.
Muscle strengthening programs, as done by physical therapists and rehab specialists, is also highly regarded as a treatment for SIJ instability. When done properly, muscle strengthening and stretching can realign the body structure to remove stress on the joint. However, the muscles cannot provide enough power to compress the SIJ sufficiently to push out the excess fluid, so the lesion remains.
Injection therapy, such as prolotherapy, is use of an irritant injected into the joint space, or surrounding ligaments. This is done in an attempt to create additional scar tissue which will help the ligaments hold the SI joint together. But, without removing the excess fluid, the best it can do is hold the SIJ in a separated position.
The only method available to provide the correct amount of pressure, direction, and time to effectively compress the weight bearing portion of the SIJ to eventually result in permanent removal of excess fluid, re-establishment of ligamentous integrity by re-integration of the ligament into the joint surface, restoration of muscular balance, and normalization of joint function is Category 2 blocking. When done properly, muscle strength will be increased immediately after the procedure, even without a Serola Sacroiliac Belt.
Because of the way they fit together when supine, the wedge shaped surface of the sacrum fits into the wedge formed by the two iliac surfaces. With proper placement, the pelvic blocks gently align and compress the sacroiliac joint to remove the excess fluid. When the ilium is held in the correct position, body weight will push the sacrum into the ilium, slowly force out the fluid, and allow the joint surfaces to come together so the ligaments can bond and heal. The bands of the interosseous ligament are positioned so that they can re-integrate into the bone's surfaces.
The correct positioning of the blocks on the pelvis and the length of time the procedure is performed is critical. When done improperly or for too long, this procedure can worsen the lesion and cause more problems, so it must be monitored carefully by one trained to do so. The Category II procedure is only available through chiropractors who practice Sacral Occipital Technic. Category 2 was developed by Dr. Major B. DeJarnette, a chiropractor, and osteopath, who founded Sacral Occipital Technic (SOT).
My own experience and research had demonstrated that this treatment has far-reaching applications in helping people with muscular pain throughout the body. Although it has been used since 1965, it is little known and practiced. Hopefully, with better understanding of the biomechanical effects of the nutation lesion, category 2 will become a central tenet in care of the musculoskeletal system. When one understands the potential benefits of this treatment for all of mankind, one realizes the necessity to educate more chiropractors to carry on this work.
Once together, the joints are held only by surface tension, with the assistance of the weak ligaments and muscles, so it will re-open again. Blocking must be repeated consistently until it is holding and then must be monitored so that the lesion doesn't return. After the blocking is holding (the blocking is no longer needed), it still takes a while for the ligaments to heal to a point where other treatment to the area can be tolerated. Until then, no blocking while prone, no adjusting, manipulation, or mobilization should be done to the SIJ for about 4 - 8 weeks, depending on the initial severity. We should be observant of returning symptoms during that period of time and get a check-up as soon as reasonable if they do. It is very important that the SIJ lesion be given time to heal or it will always be a source of chronic muscular tension and pain.
Generally, I find that, if the blocking is holding for about four months, it is going to hold permanently if other structural problems, such as lumbo-sacral hypomobility, trauma or deep stretching, don't cause recurrence.
Observance of my Do's and Don'ts is important, as well as realigning the spine, to avoid other structural influences toward recurrence.
Wearing the Serola Sacroiliac Belt between treatments will help hold the joints together and resist re-occurrence of the lesion. Once the SI joint is healed, the Serola Sacroiliac Belt can be used as a preventative during work or play.
The first (non-elastic) layer of the Serola Sacroiliac Belt is designed to keep the joint surfaces from opening beyond normal range of motion, thereby removing stress from the ligaments and normalizing the muscular spasm/inhibition complex.
The second (double-pull elastic) layer is designed to compress the joint and push the ligamentous bands back toward their insertion, helping them reintegrate into the joint surfaces. Our elastic has the proper tension to do the job correctly. It also pulls the pelvis posteriorly, improving posture.
If you are seeking proper care to stabilize your sacroiliac joint through Category 2 Blocking, finding a qualified chiropractor who is certified by one of two organizations (SORSI: www.sorsi.com) or (SOTO-USA: www.soto-usa.org) is the best way to go.
Secondarily, find a chiropractor has taken our video course by emailing us at firstname.lastname@example.org. This video presents an alternative way to use the blocks but is not as comprehensive in scope as SOT treatment. A third, less viable option for the chiropractor is to learn the basics of treatment through an article at http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=51334.
Along with blocking, proper rehabilitation can begin but it is critical that the sacroiliac joint is properly stabilized with the Serola Sacroiliac Belt. If this belt is not worn during exercise and stretching, the likelihood of opening the sacroiliac joint is almost 100%, especially during the period of Category 2 blocking and for about 6-8 weeks after blocking is no longer needed.
A physical therapist can provide an excellent compliment to blocking. It is important to know the proper muscles to exercise and stretch, along with and safe procedures for doing so. Ideal treatment combines the blocking procedures of category 2, done by a chiropractor, with the correct exercise and stretching routine as taught by a physical therapist or rehab specialist. For this reason, I have developed a video showing which muscles to stretch and strengthen, along with the biomechanics behind the concept. A patient's version, showing the recommended exercises and stretches, is available. But, a more comprehensive version is available for physical therapists and doctors, which is designed to help them monitor your care and ensure that you stay on the correct path toward healing. Remember, when seeking care from a chiropractor, physical therapist, or other doctor, ask if they are familiar with the Serola System, and make sure that you wear a Serola Sacroiliac Belt while doing any exercise or stretching.
Cautions That Must Be Taken During the Stabilization Period
Due to the delicate nature of the tissues, adjustment, manipulation, or mobilization, of the SIJ should be avoided until the SIJ has stabilized and the ligaments have healed. To help ensure this, it is strongly recommended that these actions should be avoided for a period of 6-8 weeks after pelvic blocking has no longer been needed. Once stable, manipulation has shown to be of significant assistance in structural balancing and symptom relief. Afterwards, chiropractic adjustment, or manual manipulation, can be very beneficial in re-aligning the sacroiliac joint, along with a proper exercise regimen. The idea in rehab is to balance the counter rotation of the two sides of the pelvis by rotating one side anteriorly and the other side posteriorly, as needed, while simultaneously rotating the whole pelvis backwards, toward neutral pelvic tilt. In other words, rehab should be designed to align the pelvis with gravity.
In a study of 20 patients with SIJD , having one ilium rotated posteriorly and the other relatively anteriorly, Cibulkafound that manipulation (manual thrust) to the posterior ilium brought it anterior and also brought the opposite side, which was anterior, to a more posterior position. As a result, both sides were brought closer to neutral pelvic tilt. This can also be done with the pelvic blocks, when used prone.
The Serola Sacrotrac traction pillow may provide significant help in stabilizing the sacroiliac joint by removing stress on the SIJ from the lumbar spine. It can be used during the 6-8 week healing period.
1. Cibulka MT, Delitto A, Koldehoff RM: Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain. An experimental study. Physical therapy 1988, 68:1359-1363.