The SIJ is the joint between the lower segments of the spine, the sacrum, and the illium bone of the pelvis. The SIJ is given structural support by strong ligaments and muscular support gives the SIJ some degree of dynamic stability. Movements of the SIJ are subtle and can be confusing; however the main movements which occur at this joint are nutation and counter-nutation. Basically speaking, nutation refers to the top end of the sacrum tilting forward relative to the Illium and counter-nutation refers to the top end of the sacrum tilting backwards relative to the Illium.
What is Pelvic Instability?
Pelvic instability refers to uncontrolled counter-nutation of the SIJ. This puts direct stretch on the long dorsal ligament which is highly innervated with nerves and can cause pain often felt in the buttock and down the leg. The combined actions of several muscles are critical to achieve stability of the SIJ, including trasverse abdominus, multifidus, pelvic floor muscles, the gluteal muscles, latissimus dorsi, obliques and erector spinae. Weakness or poor neuromuscular recruitment of these muscles can cause sustained counter-nutation of the sacrum, increasing the risk of SIJ irritation.
Treating Pelvic Instability and SIJ Pain
Assessment to determine which muscles are deficient in stabilising the pelvis is critical for the treatment of SIJ pain. For acute SIJ pain, any exercise or movement which brings the sacrum into nutation should reduce pain. This includes SIJ mobilisations, stretching the hamstrings to inhibit them from pulling the sacrum into counter-nutation, taping across the SIJ or into nutation as well as traction in line of the SIJ to reduce stretch on the long dorsal ligament. Initially to achieve further pelvic stability, exercises to improve the strength and control of transverse abdominus are key. To then achieve dynamic control of the pelvis, strengthening the other muscles which stabilise the pelvis (Most commonly gluteus maximus and latissimus dorsi) is required.
Written By Jack Hickey Exercise Physiologist at MD Health Pilates
Rehabilitation Following Arthroscopic Surgery for FAI Hip Pain
Post-operative rehabilitation protocols for FAI Hip pain must factor in advancements in surgical techniques when considering time lines for goals and progressions. Rehabilitation following arthroscopic debridement of bony abnormalities for FAI differs to traditional post-operative hip rehabilitation, as there is no hip dislocation with arthroscopic surgery, therefore greater ROM is allowed earlier on in rehabilitation. In any case, progression of rehabilitation should always be based on each individual’s presenting signs and symptoms rather than on a time line or recipe approach.
Initial phase of rehabilitation should focus decreasing inflammation, restoring normal ROM, gentle stretching, re-establishing correct muscle recruitment and isometric strengthening for the muscles around the hip. Optimising position of the femoral head in the acetabulum by strengthening the deep external rotators of the hip, especially quadratus femoris, is crucial as well as restoring gluteus minimus function. Once these things have been achieved, progression can be made to the intermediate and then advanced stages of rehabilitation.
Intermediate and Advanced Phases
The intermediate to advanced stage of rehabilitation should focus on restoring muscular strength and endurance; achieve optimal neuromuscular control, balance and proprioception as well as increasing core and pelvic stability. Normal function of the hip musculature must be restored during this phase of rehabilitation, with a progression from isometric exercises to more functional type movements. Increasing strength of gluteus medius muscle as well as further strengthening deep external rotators of the hip is also particularly important during this phase, due to the client’s weakness in these muscles. This will also assist in the progression to single leg exercises. The close relationship between the hip and the pelvis means that strengthening exercises need to incorporate lumbo-pelvic and trunk stabilisation exercises for return to full function.
References for Further Reading
Enseki, KR, Martin, R & Kelly, BT 2010, ‘Rehabilitation after arthroscopic decompression for femoroacetabular impingement’, Clin Sports Med, vol. 29, no. 2, pp. 247-55, viii.
Philippon, MJ, Stubbs, AJ, Schenker, ML, Maxwell, RB, Ganz, R & Leunig, M 2007, ‘Arthroscopic management of femoroacetabular impingement: osteoplasty technique and literature review’, Am J Sports Med, vol. 35, no. 9, pp. 1571-80.
Stalzer, S, Wahoff, M & Scanlan, M 2006, ‘Rehabilitation following hip arthroscopy’, Clin Sports Med, vol. 25, no. 2, pp. 337-57, x.
Wahoff, M & Ryan, M 2011, ‘Rehabilitation after hip femoroacetabular impingement arthroscopy’, Clin Sports Med, vol. 30, no. 2, pp. 463-82.
Flexibility- Correct Stretching Techniques Benefits and Myths
Flexibility refers to a joints ability to move through its full range of motion. Both muscles and ligaments, which attach around a joint, can influence a person’s ability to stretch into different positions. Now don’t compare yourself to the person next to you who is able to touch their hands on the floor without any warm up, as some people due to laxity (stretchiness) in their ligament are genetically advantaged. However, that’s not to say that correctly stretching over a period of time can’t change your current flexibility.
Being more flexible has many benefits.
Joints that can be worked through their full range of motion allow increased biomechanical performance and decrease the risk of injuries.
Can reduce muscle soreness and fatigue, especially after one of our tough sessions!
Aid in promoting better posture, especially after those long days at work.
Allows greater health of your muscles and joints; stretching assists by increase the amount of blood to that area which contain vital nutrients that keep muscles healthy, and lubricate your joints.
The Flexibility Program at MD Health is tailored specifically to stretching major muscle groups in your body in the most efficient and effective way. In order to get the most effective stretches there are a couple of guidelines that need to be followed.
Never stretch when the body is cold!
Studies have shown that when a muscle has not been subjected to a correct warm up, it can in fact make them more susceptible to injuries such as muscle tears.
It should never be painful!
Stretching to the point where “you can really feel it” can also increase your change of both damaging the muscle and the joints themselves. A great analogy is referring to an elastic band. If you take muscle being the elastic band and you stretch it really quickly and tightly, when letting go it actually contracts at a faster rate and is more likely to get even tighter than it already was. The same works with your muscles. It can also put great stress on the ligaments that surround your joints, which once stretched and loosened cannot be made tighter!
Stretching should be GENTLY held from anywhere between a minimum of 20 seconds to 2 minutes.
Going back to the elastic band analogy it is a lot better to slowly stretch it over a long period of time. Muscles react in the same way. A prolonged period of gentle and stained stretch will allow the muscle to loosen without cause unnecessary stress or unwanted damage.
Workout Wednesday: Bridging Exercises: This week Jack Hickey, Exercise Physiologist at MD Health, and Mark Charalambous, Physiotherapist at MD Health, demonstrate the correct technique for basic, intermediate and advanced bridging exercises.
Bridging is a great way to strengthen the glute and hamstring muscles.
Workout Wednesday: Bridging Exercises:
For more of Workout Wednesday visit our YouTube channel:
Femoro-Acetabular-Impingement FAI Hip Pain Explained
Functional Anatomy of the Hip Joint
The hip joint is a very stable ball and socket joint between the head of the femur and the acetabulum of the pelvis. The joint is enclosed by the acetabular labrum and joint capsule which increase joint stability. The main function of the hip joint is to support forces being transferred between the upper limbs, trunk and lower limbs. There are three groups of muscles which all play a role in the complex movement of the hip joint. The role of the deep muscle system is to control the position of the femoral head in the acetabulum as well as contributing to joint stability through a proprioceptive role. The intermediate muscle system controls movement of the pelvis on the femur during weight bearing as well as being secondary stabilisers of the femoral head in the acetabulum. The superficial muscle system is primarily used for force production around the hip joint.
What is FAI?
Femoro-Acetabular-Impingement (FAI) is a defect in the normal mechanics of the hip joint due to abnormal bony contact between the head of the femur and the acetabulum of the pelvis. This abnormal bony contact generally causes pain and discomfort in the anterior/later hip and groin area. Sitting for prolonged periods or activity requiring a large range of motion around the hip such as sports involving kicking actions often cause pain for people with FAI. FAI is more common in a younger active population and over time can lead to damage to the soft tissue structures, labral tears, muscle inhibition, bursitis, tendinopathy and osteo-arthritis.
What causes FAI Hip Pain?
There are two main forms of bony deformity that contribute to FAI Hip Pain either in isolation or in combination with each other. CAM impingement refers to a bony growth on the neck of the femur which butts up against the rim of the acetabulum during hip flexion and internal rotation. Pincer impingement refers to a thickening and widening of the acetabular rim, causing over-coverage of the acetabular rim in relation to the femur which does not allow enough room for the head and neck of the femur to move without making contact with the acetabular rim. Other factors which can contribute to FAI include tight posterior joint capsule, anterior instability and poor or delayed muscle activation of glute min, quadratus femoris and/or illiacus.
Treating FAI Hip Pain
Conservative management of FAI focusses on improving hip joint mechanics and optimising movement by improving muscle activation and strength of glute minimus and quadratus femoris, reducing posterior capsule tightness and strengthening the superficial muscle to a neutral position to avoid excessive anterior movement of the head of femur. In some cases surgical intervention may be necessary to reduce abnormal bony contact between the femur and the acetabulum by debriding the abnormal bony growth through arthroscopic surgery. If surgery is performed, pre-surgery and rehabilitation will focus on maximising hip joint function and addressing the factors outlined above during conservative management.
Written by Jack Hickey Exercise Physiologist at MD Health Pilates