Sacroiliac Joint Pain: Sacrum or Ilium?

(From the March 2005 The ‘G’ Note)

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A common dilemma for the Gonstead doctor when presented with a suspected sacroiliac subluxation is: do you adjust the sacrum or ilium when there is justification for either. In addition to the other tests used to determine not only sacroiliac involvement but also sacral or ilium subluxation is the prone leg check.

The patient is put in the prone position and bilateral leg lengths are compared. If the leg on the side of the sacroiliac subluxation is long and there is tenderness and edema at the postero-superior margin of the sacroiliac joint space, a posteriorly rotated sacral subluxation is suspected. The ilium usually compensates AS-IN major on the side of the posteriorly rotated sacral subluxaion with a resultant “long leg.” [Gonstead Methodologies uses the listing SA-ASIN.]

If the leg is long on the involved side and tenderness and edema is found at the postero-inferior margin of the sacroiliac joint space, suspect an AS-IN major ilium subluxation.

If the leg is short on the involved side and the tender, edematous area is palpated at the postero-superior margin of the sacroiliac joint space, suspect a PI-EX major ilium subluxation (of course, it is confirmed on x-ray).

Physical Signs

AS-IN major ilium subluxation
• Decreased lordosis
• Internal inguinal pain
• Inguinal ligament pain
• Ischium pain: “feels like sitting on a rock”
• Wide ilium on AP x-ray
• Small obturator foramen on AP x-ray
• Internal foot flair
• “Long leg” sign when prone
• Long-term AS-IN subluxation may cause acetabular degeneration
• May cause asymmetrical pelvic outlet.

PI-EX major ilium subluxation
• Increased lumbar lordosis
• Lateral thigh pain
• Narrow ilium on AP x-ray
• Large obturator on AP x-ray
• “Short leg”
• External foot flair
• May cause asymmetrical pelvic outlet

Tips On The Sacroiliac Joints
• An ilium subluxation is usually exacerbated by walking or standing.
• A lumbo-sacral or lumbar subluxation “disc involvement is usually exacerbated by sitting.
• Acute pain usually involves a disc; subluxations of the ilia rarely exhibit acute pain.
• Adjust the thick disc (D1) in the afternoon; adjust the thin disc (D4-D6) in the morning.
• If you suspect an ilium subluxation, compare the obturator sizes.
• If there is a PI-EX major on the side of a posteriorly rotated sacral misalignment, adjust the ilium (adjusting the sacrum drives the ilium more external).
• An EX ilium subluxation can cause knee pain.
• If the sacrum appears normal on x-ray, and there are significant obturator changes, suspect an ilium subluxation.
• Other factors can alter leg length: e.g., anatomical short leg, fractures, muscle spasms, knee and ankle pain, etc.