An Integrative Guide to Sacroiliac Joint Dysfunction:

UnderstandingYourLowBackandButtockPain

By,DavidMesnick,PT,OCS,cMDT

ContributionsbyTravisBarefoot,DPT

www.pt360atl.com

Overview

Themusculoskeletalsystemisanintricatenetworkofbones,muscles,andotherconnectivetissuethatservestoprovideformandstructuretoourbodies,toproducemovement,andtoprotectourinnerorgans.“(Professionalsinthemedicalfield)usemanualmedicinetoexaminethisorgansysteminamuchbroadercontext,particularlyasanintegralandinterrelatedpartofthetotalhumanorganism.”4

“SkilledPhysicalTherapistsareaninvaluablepartofateamofhealthprofessionalsprovidingspecialknowledgeandabilitiesthatcanenablethedeliveryofaneffectiverehabilitationprocess,especiallyforpatientswithmusculoskeletaldysfunctions.”5Theinformationprovidedinthispamphletservestobettereducateyouasapatientontheissuescausedbythesacroiliacjoint,andhowPhysicalTherapistusecertainmethodstoexpeditetheprocessofrecovery.

Anatomy

Thesacroiliacjoint,abbreviatedas“SI”joint,isaconnectionoftwobonesjustbelowthelumbarvertebrae(yourlowerback).Thisjointiscomposedofthesacrumandiliumbones.Justasthekeystoneinamasonryarchservestomaintainthestructuralintegrityofdoorwaysandceilings,thesacrumisabiologicalequivalenttothestructuralintegrityofthepelvis.

Thereare2partstotheSIjoint;oneithersideofthesacrumwehave2iliums(placeyourhandsonyour‘hips’andyou’refeelingthetopoftheilium)andbetweentheplacementsofyourhandsbeingonyourhipslaysthesacrum.Thisisthe“SIjoint”.Previousschoolofthoughtbelievedthisjointtoberelatively‘fixed’,orextremelystable.However,moreup-to-dateresearchoutlineshowthemobilityandsynchronicityofmovementatthisjointplaysanextremelyimportantroleinthenormalmotionofthehumanbody.

Normalmovementofthesacruminrelationtotheiliumisdescribedas‘nutation’(andconversely,‘counternutation’),whichcanbedefinedasoscillatorymovementoftheaxisofarotatingbody1.Anotherwaytothinkofthisistoimaginethetopofthesacrummovingforwardanddowncomparedtothebottom,andthentheoppositewouldthenbecounternutation.Thesemotionsoccurinconjunctionwithothermovementslikewalking,bendingforward/backward,andevenbreathing!

Signsandsymptoms

WhenthereisadisturbanceinthenormalmovementoftheSIjoint,anarrayofsignsandsymptomsmaybepresent.InaPhysicalTherapyexamination,thetherapistwillobservethemotionoftheSIjointandotherinvolvedstructuresviaspecialteststhatareoutlinedinthishandout.Althoughspecialtestsarepresenttoserveasabasisforexamination,realizethateveryevaluationmayvaryfromtherapisttotherapist.“PeoplewithSIjointdysfunctionwillhavesymptomsrangingfrompainatthejointitself,inthelowerback,orevendownthethighandgroin.Theremaybeapresenceofgeneralizedstiffnessorburningsensationatthejoint”2.SometimesanSIdysfunctioncanactuallycausepainontheoppositesidefromwherethetrueproblemlies!3

Muscles

Piriformis

InnervatedbyS1andS2

WillbecomeoveractiveorfacilitatedwithanSIJD.

Tendernessisusuallyfeltinthemusclebelly(deepbuttockpain)orattheorigin(sacrum)orattachment(atthegreatertrochanter)

BecomestheprimarystabilizeroftheSIJinthepresenceofSIJDwhichisafaultypattern

Cancompressthesciaticnerveandcancausepiriformissciatica(link)orpiriformissyndrome

Overstretchingoftenincreasesoveractivityorfacilitationandleadstoincreasedpainorsciatica.

Iliopsoas(iliacus+psoasmuscle)

iliacus:L2-L4(femoralnerve)psoas:L1-L3(anteriorbranchesoflumbarplexus)

DysfunctionatL2-3causeshypertonicityofthehipflexorgroupmuscles,whichcanmimicalabraltear

Hamstrings

Bicepfemoris:tibialnerve+commonperonealnerve,semitendinosus:tibialnerve,semimembranosus:tibialnerve

Hamstringtearsareoftenaresultoftheinactivationofthegluteusmaximusduringathleticactivity.Overactivation/facilitationofthehamstringscanbecausedbysacraldysfunctions,T-Ljunctiondysfunctions,andevenanklesprains.

Neuraltensionisanadditionalsymptomoftighthamstrings.Whenneuraltensionincreases,thehamstringsbecomeshortenedtoprotectthenervesthatrundowntheleg(think:sciaticnerve).

QuadratusLumborum(QL)

T11-L2innervation

Mostfrequentmuscularcauseofbackpain

HypertonicityononesideassociatedwithFRSdysfunctionatT12-L1tothatside.

PossiblytheprimarystabilizeroftheL-spine

CommonwithonesidedsittersandstandersinSIJD

LumbarMultifidus

Innervatedbyposteriorbranchesoflumbarspinalnerves

Whenthereiscompromisetothedeeplayerofthespinalcolumn(vertebrae/discs/ligaments)themultifidus,akeystabilizingmusclethatnormallyprotectstheinjuredspinaljoint,quicklyshrinksby25%andfailstoactivatecorrectly.Thismeansthekeymusclesthatnormallykeepourbacksfunctioningproperlyandwithoutpaincannolongerdtheirjob.8(Jemmett)

SerratusAnterior

Innervation:C5-7(longthoracicnerve)

BecomesinhibitedasaresultsofERS(extension)dysfunctionsintheupperthoracicspine,orfromalossofinferior/posteriorglideoftheG-Hjoint

Asaresultofthedysfunction,scapularwingingcanoccur.Thisequatestopoorscapularstabilization,cervicalpain,shoulderimpingement,anduppertrap/levatorscapulaetriggerpoints.

Internal&ExternalObliques

Innervation:intercostalnerves7-12,subcostalnerve

Innercostalnerve8-12,iliohypogastric,ilioinguinalnerves9

Triggerpointsintheexternal/internalobliquesandtransversusabdominusallhavesimilartriggerpointpatternsintotheabdominalcavity.Referralpatternscanmimicheartburnandepigastricpain.(www.bodyworks.com)

TransversusAbdominus

Innervation:T8-12

Thismuscle,likethemultifidus,isakeyplayerinspinal(core)stabilizationinthelowback.Injurytothedeeplayerofthespinalcolumnresultsindecreasedcontractileabilityofthe“TrA”.CausesalsostemfromThoraco-Lumbarjunctiondysfunctionsandlowerthoracicdysfunctions.

Thisleadstotight/overactivehamstrings,increasedneuraltension,andlowbackpain.

Onlyneed3-5%ofTrAcontractionforstability

Onlytrainaftermechanicaldysfunctioniscleared

RectusAbdominus

Innervation:7-12intercostalnerves

Acauseofdysfunctionofthismusclegroupisaninferiorpubicdysfunctiononthesamesideasthesymptoms,whicharesamesideadductorpainandpubicpain(symphispubis).

Adductors

InnervationL2-L4

Arefunctionallyconnectedtotheabdominalobliqueslingofsupportfortheanteriorpelvis

Whenhypertonicthepulloftheadductorscanresultinaninferiorpubicshear(symphysispubis)

Diaphragm

InnervationisthephrenicnerveC3-C5

Thediaphragmfunctionsinbreathing.Duringinhalation,thediaphragmcontractsandmovesintheinferiordirection,thusenlargingthevolumeofthethoraciccavity(theexternalintercostalmusclesalsoparticipateinthisenlargement).Thisreducesintra-thoracicpressure:Inotherwords,enlargingthecavitycreatessuctionthatdrawsairintothelungs.

GluteusMaximus

InnervationL5,S1,S2

PrimaryStabilizeroftheSacroiliacjoint

CanbecomeunderactivewithaLeftonRightsacraltorsionorRightonLeftSacraltorsion,andmechanicalproblematL4orL5onthesameside

UnderactivityoftenresultsinchronicHamstringtightnessorinjury.

GluteusMediusandMinimus

InnervationL4,L5,S1

Primarystabilizerofthehipandknee

BecomesunderactivewithaLeftonrightsacraltorsion,rightonleftsacraltorsion,andL4orL5mechanicalproblemoftenontheoppositeside.

UnderactivityisacommoncauseofITBsyndromeorPatellarFemoralPainSyndrome

TensorFasciaLatae/Iliotibialband(TFL/ITB)

InnervationofTFLisL5-S1

UnderactivityoftheGluteusMediuscausetightnessintheITB/TFLwithchronictightness.

Pelvicgirdlemusclegroupsandslings

The‘pelvicgirdle’simplyreferstotheenclosedstructurethatisformedfromthecollectionofbonesthatmakeupthepelvis.Musclesthatattachtothepelvismakeupcomplimentarymusclegroupscalled“slings”.Thesemusclegroupsallowforeithertheproductionofmovementorstabilizationtoreducemovement.However,theseslingscansometimesbecompromisedduetostructuralmisalignmentintheSIjoint.15

Theanteriorobliqueslingthatiscomposedoftheserratusanterior,externalandinternalobliques,rectusabdominus,transversusabdominus,andlowerlimbadductors“providesstabilitybyactinglikeanabdominalbinder,compressingtheentirepelvicgirdle,especiallythefront,securingthesymphysispubis”.6

Whentheadductorsofthelegbecomeoveractive(hypertonic),theycandistortthepositionoftheirattachmentatthepelvisandcauseaninferiorshearatthepubicsymphysis.

Thelateralslingthatismadeofthegluteusmedius,andadductorsononesideofthebody,aswellasthequadratumlumborum(QL)ontheothersideprovideslateralstabilitywhenwalking.7Usually,thegluteusmediuscanbecomeunderactiveorhypotonic,resultinginabnormalpositioningofthepelviswithambulation.

Theposteriorobliqueslingiscomposedofthelatissimusdorsi,thoracolumbarfascia,andgluteusmaximus(onthecontralateralsidefromthelatissimusdorsi).

“Theactionofthesemusclesalongwiththefascialsystemisthoughttobothfighttherotationofthepelvisthatwouldoccurduringgaitaswellasstoreenergytocreatemoreefficientmovement.”7MuscleactivityofthearmsorlegsinfluenceeachotherviatheLumbarspine

Thedeeplongitudinalslingisformedfromtheerectorspinaemusclegroup,thoracolumbarfascia,andbicepfemoris(portionofthehamstring).“TheDLSusesboththethoracolumbarfasciaandparaspinalsystemtocreatekineticenergyabovethepelvis,whilethebicepsfemorisactsasarelaybetweenthepelvisandleg.Thisslinghelpstocreatestabilityandhelpbuildaswellasreleasekineticenergytohelpmoreefficientmovement.”7

Types of SIJD

HypermobileorLooseSIJ

HistoryofTraumaorhormonalchange

Waddlinggait

Secondarytolumbarpathology

Difficultybendingforwardandstandingononeleg(+forwardflexiontestandstorktestonthesameside)

ActivestraightlegwillbeeasierwithcompressionandSIbelt/coresshortsmayhelpwithstability(link)

Responsetomobilization,manipulation,taping,corestabilitywhenjointmechanicsareimproved,andprolotherapy(link)13

Excessivecompressionwithligamentouslaxity

Traumaoverashortperiodoftimeorrepetitivetraumaoveralongperiodoftime

Difficultybendingforwardandstandingononeleg(+forwardflexiontestandstorktestonthesameside)

ActivestraightlegraisewillnotbeeasierwithcompressionandSIbeltandcoreshortswillnothelp.

RespondstoMyofascialrelease,dryneedling,mobilization,manipulation,taping,corestabilitywhenjointmechanicsareimproved,andprolotherapy(link)13

HypomobileSIJ

Compressedjointduetomuscleimbalance

Paincanswitchsides

Painisintermittent-cangoawayandreturn

Oftenananteriorrotationwithleftonrightorrightonleftsacraltorsionisobserved

Overactivepiriformiscausestoeoutgait(link)andpiriformissciatica(link)onthesameside.

Abletostandononeleg

AbletoliftbothlegswithoutcompensationwiththeActiveStraightlegtest

TreatmentiscorestabilizationandMyofascialrelease/dryneedling13

TypesofhypomobileSIJD

AbsentCore

CanresultfromPost-partum

Butt-gripper(showpic)

UnderactiveTransversusabdominus(core)andpubococcygeus(anteriorpelvicfloor-andmaycauseincontinencelinktopic)

Overactivepiriformisbothsides,multifidusanderectorspinae(lowbackmuscles,andposteriorpelvicfloor-maycausecoccydnia13

TwistedCore

Theresultofaunilateral(onesided)lumbarspineorSIjointdysfunction

ResultsinanAnteriorlyrotatediliumandLeftsacraltorsion

UnderactiveunilateralTransversusabdominus(core),and/ormultifidusandanteriorpelvicfloor

Overactiveunilateralpiriformisandposteriorpelvicfloor

InvertedCore

Overactivemultifidusanderectorspinaemusclesbothsides13

StiffJoint

ThejointdoesnotmovesecondarytoAnkylosingspondylitis,capsularfibrosis,orjointfusionsecondarytoadvancedage.

Treatmentismobilizationandflexionexercises

TheSIJjointhasahardendfeelwhenmobilized13

Diagnostic Testing and Physical Exam

SIJointProvocationTests

SIJtestingshouldbedoneonpatientswithbuttockpain,withorwithoutlumbarorLEsymptoms.MostSIJisunilateralandaroundthePSIS.Forallprovocationtests,a+testisreproductionofsymptomsand–testisnoreproductionofsymptoms.

DistractionTest:Thepatientissupinetheexaminerappliespressureto“spread”theASISs.

CompressionTest:Thepatientisinaside-lyingposition.Thetesterisbehindthepatientwithbothhandsapplyingadownwardpressurethroughtheanteriorportionoftheilum,spreadingtheSIJ.

ThighThrustTest:Thepatientissupineandthehipisflexedto90degreesandthekneeisbent.ThetesterthenappliesaposteriorshearingforcetotheSIJthroughthefemur.Avoidexcessivelyadductingduringthisexam.

Gaenslen’sTest(Right):Thepatientissupinelyingnearthesideoftable.Theexaminerstandsonsideofpatientsandplaceslegclosesttothemoffedgeoftable.Theexaminertheninstructsthepatientstoactivelyflextheoppositelegtotheirchestandhold.Theexaminerthenappliespressuretotheleghandingoffedgeoftableforcingthehipintoextension.

SacralThrustTest:Thepatientisproneandtheexaminerappliesananteriorpressurethroughthesacrum.

2outof4provocationtests(distraction,compression,thighthrustorsacralthrust)havesensitivityof.88andspecificityof.78.+Likelihoodratio(LR)of4.00and–LRof.16forSIJpathology.

3outofall6provocationhavesensitivityof.94andspecificityof.78.+LRof4.29and–LRof.80forSIJpathology.

LaslettM,AprillCN,McDonaldB,YoungSB.DiagnosisofSacroiliacJointPain:ValidityofIndividualTestsandCompositesofTests.ManualTherapy.2005:10;207-18.

SIJDysfunctionGoldStandardTesting

Thecurrent‘goldstandard’fordiagnosingsacroiliacpathologiesisadiagnosticnerveblock,wherebyanaestheticisinsertedintotheSIJ,underfluoroscopyguidance.Someauthorsarguethatifthepatientachieves50-75%painrelief,on2occasionswithshortandlongactingnerveblock,adiagnosisofSIJdysfunctioncanbemade,butwithcaution(vanderWurffetal2006,Berthelot(citedMaigneetal).

FortinFingertest

SimplyplaceyourfingerdirectlyontheareaofyourpainwithONEFINGERtwotimes.

Accordingtotheresultsofthisstudy,ifyoupointtotheexactspotwherethesacroiliacjointislocated(rightorleft)eachtime,yourpainislikelycomingfromtheSIjoint.Seediagrambelowforlocationofsacroiliacjoints.

TheSIjointsarelocatedimmediatelybelowandtotheinsideoftheposteriorsuperioriliacspines(PSIS),whichfeellikesmallboneybumpsoneachsideofyourlowerback.Eithersidecanbepainful

StandingFlexiontest

Thepatientisinstructedtobendforwardfromastandingpositionandthefeethipwidthapart,attemptingtotouchthefloorwhilethetherapistfollowsthePSIS’stoseewhetheroneappearstomovemoretowardsthehead.IfoneofthePSIS’smovestowardstheheadthetestisconsideredpositive.ApositivetestissuggestiveofaSIJDonthepositiveside.

Storktest

TheexaminerplacesonethumbjustbelowthePSISandtheotherthumbonthesacralsulcus.Withthepatientinstandingandarmsunsupported,thepatientisinstructedtoliftthetestedsidekneetowardstheceilinguntilhehasreached>90degreesofhipflexion.Ifpositive,thereisastrongindicationofSIJDpresentonthatside.Normally,thePSISshouldbegintodropdown(inferiorly)after90degreesofhipflexion.ThistestisconsideredpositiveifthePSISdoesnotmoveormovesupward(superiorly)3.

Longsittest

Theexaminergraspsthepatient’slegsabovetheanklesandfullyflexesthem,thenextendsthem.Theexaminerthencomparesthetwomedialmalleolitoseeifadifferenceinpositionispresent.Havethepatientsitup,whilekeepingthelegsextended.Comparethepositionofthemedialmalleoliagaintoseeifthereisachange.Ifthereisaposteriorinnominate,thelegthatappearedshorterwilllengthenwiththesitup(Orwillgofromshorttolong).Ifthereisananteriorinnominate,thelegthatappearedlongerwillshortenwiththesitup.(Orgofromlongtoshort).Theaffectedsideislabelbasedonwhichsidetheexaminernoticedapositiveseated,standing,and/orstorktest.Thistestcanhelpindifferentiatingbetweenatrueleglengthdiscrepancyandafunctionalleglengthdiscrepancyduetoasacroiliacdysfunction.

Leglengthmeasurement

AleglengthmeasurementcanbemadewiththepatientinsupinestartingfromunderneaththeASISandendingunderneaththemedialmalleolusonthesameside.Anydifferencenotedwillbeatrueleglengthdiscrepancyandmaybereasontointroduceaheelliftororthotic.

Seatedflexiontest

Thepatientisseatedwiththefeetontheground,armsbetweentheknees,andthekneesapart.TheexaminerplaceshisthumbsunderneaththePSIS’sonbothsidesandasksthepatienttobendforwardasfaraspossible.Ifonethumbmovesmoretowardstheheadthenthetestispositive.ApositivetestissuggestiveofaSIJDonthatside.3

Pronehipextensiontest

Thepatientliesonherstomachandliftsonelegwiththekneestraightabout6inchesoffthetable.Thetestisrepeatedontheoppositeside.Ifonesideseemsignificantlyhardertodoand/ortherewasasignificantdelayinthegluteusmaximuscontractionduringhipextensionthenthissideispositive.ApositivetestsuggestsgluteusmaximusunderactivityandmaybemeanthereissamesideSIJDoralumbarfacetproblem.

SingleleggedSquattest

Thepatientstandsononelegwhiletheotherlegisliftedoffthegroundinfrontofthebodysothatthehipisflexedtoapproximately45°andthekneeofthenon-stancelegflexedtoapproximately90°.Thearmsareheldstraightoutinfront,withthehandsclaspedtogether.Fromthisposition,squatdownuntilabout60°kneeflexion,andthenreturntothestartposition.Notethelegthatwastested.IfthekneebucklesinwardthanthetestispositiveforpoorhipstabilizationandweakGluteusmedius.

Treatment and Exercises

PhysicalTherapyandotherconservativetreatments

APhysicalTherapistusesavarietyofmanualtherapytechniques,stretching,exercises,andmodalitiestoaddressthesourceofapatient’spain;theyalsoworktoalleviatetheaggravatingsymptomsthatinhibitnormaldailyactivities.ThegoalofPhysicalTherapyisnotonlytohelpapatientreturntotheirpremorbidstatus,buttohelpincreasepatients’bodyawarenesssothattheywillbecomemoreindependentinrecognizinghowtheycantreattheirownpainthroughspecifictreatmentstailoredtoindividualneeds.

Dryneedling

AnadditionalserviceofferedbyPhysicalTherapistsforthetreatmentofSIjointandbackpain,dryneedlingisquicklybecomingago-totreatmentmethod.Withtheuseofaveryfinepointneedle,thetherapistwilllocatethepresenceofatriggerpoint,whichisatightlyboundgroupofmusclefibersthatarehypersensitiveandoftencausepain,andinserttheneedleintothatarea.Thisprocessoftencausesinstantreliefoftensioninthemusclegroup/joint.

Botoxinjections

Traditionallythoughtofasatoolforcosmeticprocedures,Botoxtherapycanbeusedtoreducepaininchronicallypainfulmuscles.“Theseinjectionsdecreasethespasmofmusclesthatcontributetobackpain,reducethesympatheticresponsethatisresponsibleforthedeep-seated‘visceral’componentoflowbackpain,andalsohelpreducetheinflammatoryresponseinandaroundthesiteofinjection.”

Steroidinjections

Inthehumanbody,painandinflammationgohandinhand.Theinflammatoryresponseofthebody,althoughanaturalprocessdesignedforprotectionoftissuesandjoints,canoftenbeextremelydebilitating.Acortisoneinjectionisusedtoreduceinflammation(andthuslyreducepain).Themedicationtakeseffectrapidly,andishighlyeffectivecomparedtoanoralequivalent.

Prolotherapy

“Prolotherapyisaninjection-basedcomplementaryandalternativemedicaltherapyforchronicmusculoskeletalpain;overseveraltreatmentsessions,afairlysmallvolumeofanirritantorsclerosingsolutionisinjectedatsitesonpainfulligamentandtendoninsertionsandinadjacentjointspaceduringseveraltreatmentsessions.”11Thistreatmentkickstartsrepairtothedamagedtissue.

PRP

PlateletrichPlasma(PRP)involvesdrawing20cc’sofblood,spinningthebloodfor15minutesinacentrifuge,extracting3-4cc’sofPRP,andinjectingthePRPdirectlyintothesiteofinjuryusingultrasoundguidedimagery.Apepperedneedlingtechniqueisusedduringtheinjectiontoinvokeaninflammatoryresponse.Theplateletshavealotofgrowthfactorinthem,whichcausesstemcellsandothergrowthfactorstocomeintothearea.Eventuallynewcollagenisformedandfillsinthetearinthetendon.ResearchshowsthatPRPinjectionsarenotasbeneficialascorticosteroidinjectionsinthefirst12weeksfollowingtheinjection,butPRPinjectionsaremuchmorebeneficialafter12weeks.At2yearspostinjectionthetendonactuallylooksnormalandshowsnosignsofinjuryonanMRI,whereasthecorticosteroidsshowednolongtermbenefits.ResearchisongoingtoinvestigatetheaffectsofPRPforDDDandcartilagedefects.TherearecurrentlynostudiesonPRPandSIJD.ThecostofPRPvariesfromproviderbutistypically$500-$1000/shot.

Reference-GosensT.PeerboomsJC.VanLaarW.DenOudstenBL.OngoingPositiveEffectsofPRPversusCorticosteriodInjectioninLateralEpicondylitis:Adoubleblindrandomizedcontrolledtrialwith2-yearfollow-up.AMJSportsMed201139:1200

PelvicClock

Directions:Lieonyourbackwithyourkneesbentandyourfeetplacedonthefloor.Imaginethatyouhaveaclockonyourstomachwiththefacepointingtowardstheceiling.Rollyourhipsbacktowards12O’clockandflattenyourbackintothetable.Nowrollyourhipsforwardto6O’clockandarchyourlowerback.Rollyourlefthipdowntowards3O’clockandthenyourrighthipdowntowards9o’clock.Tofinishrollyourhipsaroundclockwiseuntilyou’vereachedeverynumberontheclock.

Evaluation:Rolltoeachindividualnumberontheclockanddecideinwhicharea(s)youaremostrestrictedand/orhavepain.Whenyoufindthenumber(s)intheclockthatarerestrictedfollowthetreatmentguidelinesdescribedonthehandoutforeachnumberthatyouarehavingproblemswith.Alternatively,youcanholdyourpelvis6hoursacrossor180degreesacrossfromthenumber(s)intheclockthatarerestrictedorpainfulfor1-2minutes.

Reassessment:Repeatthedirectionsabovetoseeifyouhaveclearedtherestrictedareas.Youmayneedtorepeattheexercisesagaintogetthebestresults.Youcanperformthepelvicclockexerciseasmanytimesadayasnecessary.

Thepelvicclockcanbeperformedinsitting.

Thenpelviccllockcanbeperformedinstanding.

References

“Nutation/CounterNutation–YogaAnatomy.”YogaAnatomymadesimple-Information,articles,workshops,andDVDs.N.p.,n.d.Web.12Aug.2013.<http://www.yoganatomy.com/2011/01/nutationcounter-nutation/>.

“SIJointPain.”MedicineNet.N.p.,n.d.Web.10Aug.2013.<www.medicinenet.com/sacroiliac_joint_p

3,5Issacs,EdwardR.,andMarkR.Bookhout.Bourdillion’sSpinalManipulation.unknown:Butterworth-Heinemann,2002.Print.

Greenman,Ph.E..Principlesofmanualmedicine.2nded.Baltimore:Williams&Wilkins,1996.Print.

6“We’veHeardSoMuchofthe‘CORE’,WhatAboutthe‘SLINGS’?«MusculoskeletalConsumerReview.“Physiotherapy|Back,Neck,ShoulderandKneePainSpecialists.N.p.,n.d.Web.12Aug.2013.<http://www.coreconcepts.com.sg/mcr/weve-heard-so-much-of-the-core-what-about-the-slings/>.

7“Re-ThinkingFunctionalMovement:TheSlingSystemsoftheBody|BreakingMuscle.”BreakingMuscle.N.p.,n.d.Web.12Aug.2013.<http://breakingmuscle.com/strength-conditioning/re-thinking-functional-movement-sling-systems-body>.

Jemmett,Rick.Spinalstabilization:thenewscienceofbackpain.2nded.Halifax,N.S.:NovontHealthPub.,2003.Print.

“InternalObliqueMuscle|Actions|Attachments|Origin&Insertion.”GetBodySmart:InteractiveTutorialsandQuizzesOnHumanAnatomyandPhysiology.N.p.,n.d.Web.12Aug.2013.<http://www.getbodysmart.com/ap/muscularsystem/abdominalmuscles/internaloblique/tutorial.html>.

Reed,StephenCharles,PennyReed,andMichaelH.Ford.Thecompletedoctor’shealthybackbible:apracticalmanualforunderstanding,preventingandtreatingbackpain.Toronto:R.Rose,2004.Print.

“Prolotherapyinprimarycarepractice.[PrimCare.2010]–PubMed–NCBI.”NationalCenterforBiotechnologyInformation.N.p.,n.d.Web.12Aug.2013.<http://www.ncbi.nlm.nih.gov/pubmed/20188998>.

FortinJD,FalcoFJ.,AmJOrthop(BelleMeadNJ).1997Jul;26(7):477-80.TheFortinfingertest:anindicatorofsacroiliacpain.TempleUniversityMedicalSchool,Philadelphia,Pennsylvania,USA.

ThePelvicGirdle:Anintegrationofclinicalexpertiseandresearch,4ebyDianeG.LeeBSRFCAMPTCGIMS(Nov23,2010)

CrossleyKM,ZhangWJ,SchacheAG,BryantA,CowanSM.Performanceonthesingle-legsquattaskindicateshipabductormusclefunction.AmJSportsMed.2011Apr;39(4):866-73.Epub2011Feb18

Johnson,Donald(DonaldHugh)Practicalorthopaedicsportsmedicine&arthroscopy/DonaldH.Johnson,RobertAPedowitz.p.;cm.ISBN-13:978-0-7817-5812-3