Starting Running Again After Si Injury
by Emily Kraus, MD, PM&R Sports Medicine Physician, Department of Orthopaedic Surgery, Stanford University
Low back and buttock pain is a common and frustrating ailment in runners, athletes, and even the general population. Identifying the exact pain generator is often challenging, merely sacroiliac joint (SIJ) pain and dysfunction is one possibility. The SIJ has gained recent interest in the running customs due to several elite athletes withdrawing from the prestigious Boston Marathon (Sara Hall and Dathan Ritzenhein) due to SIJ issues. What is this special joint and why is information technology sidelining elevation runners? The purpose of this commodity is to help you sympathize basic SIJ anatomy including how it could be such a nagging source of pain, and what y'all should do if y'all remember SIJ pain may be thwarting your own running goals.
The Anatomy
To truly understand the anatomy and function of the SIJ, we must first discuss the pelvis and spine. The pelvis is a stable ring fabricated up of three joints: the two sacroiliac joints and the symphysis pubis (Figure i). The SIJ connects the sacrum (function of the spine) to the pelvis and plays the of import office of absorbing the multidirectional stresses and loads between the spine and pelvis. Several muscles attach to the SIJ, such as the gluteal muscles, while others play a central role in overall stability and movement of the pelvis, such equally the piriformis, hamstrings, deeper pelvic muscles, abdominals, hip flexors, and muscles of the lumbar spine. Several of these muscles are illustrated in Figure 2.
Figure 1: Anatomy of the pelvis and sacrum
Figure two: Supportive muscles of the pelvis and sacroiliac joint
Although the SIJ is a true "joint," information technology's different than the talocrural joint or hip articulation, with the overall move being limited to effectually 2 degrees of rotation and less than a millimeter of movement forward and backward. These numbers may audio minimal, but if the articulation becomes hyper- or hypomobile or gets loaded excessively, this can atomic number 82 to SIJ pain and dysfunction.
Why do runners get SIJ dysfunction?
During running, the pelvis absorbs the shock and load from the legs and transmits this load into the sacrum and upwards the spine. If the muscles of the hip, spine, and pelvis aren't providing enough stability (i.e., muscles are weak or firing at the wrong time) or when the ligaments are lax due to hormonal changes (i.east., during pregnancy) the SIJ may get into a hypermobile state. Conversely, a hypomobile state may occur if these muscles are excessively tight or if the joint is restricted due to arthritic changes.
The Symptoms
Runners may complain of an achy low back pain which tin ofttimes be pinpointed to a single location at the sacral sulcus (Figure 3) or information technology may radiate/shoot to the lower glute, back of the leg, outer thigh, or groin. The hurting is often worse with running, climbing stairs, or continuing from a seated position. Asymmetric "shearing" motions, such equally during utilize of a stair-stepper or running up/downwardly steep hills, may also exacerbate the hurting.
Figure 3: Finger (and pointer) pointed to the sacral sulcus, the upper function of the sacroiliac joint
Making the Diagnosis
SIJ dysfunction is a less common crusade of depression back hurting, thus a thorough physical examination is fundamental in making the correct diagnosis. A list explaining other potential causes is provided in the table below. Especially in distance runners, sports medicine physicians should consider stress fracture/reactions to the sacrum and do the appropriate diagnostic testing to dominion this injury out. Bank check out my previous article on sacral stress fractures for more than details.
| Other Causes of Low Back and Buttock Hurting | |
|---|---|
| Injury or Disorder | Description |
| Lumbar Disc Herniation | A disc herniation of the lower lumbar spine can lead to both localized hurting and referred hurting into the buttocks |
| Spondylolysis | A less common cause of acute SIJ pain with associated fevers and inflammation. |
| Sacroiliitis | A disc herniation of the lower lumbar spine can lead to both localized pain and referred pain into the buttocks |
| Ankylosing Spondylitis | A rheumatologic condition which unremarkably presents every bit chronic, dull pain in the back, hip, and buttock usually accompanied past morning stiffness (<30 min) which improves with activity |
| Sacral Stress Fracture | Presents as a irksome anguish in the expanse of the sacrum with radiation to the glutes, which worsens with walking, running, or hopping. Often seen with an increase in grooming book or intensity. |
| Piriformis Syndrome | Another rare, often controversial, diagnosis which ordinarily involves irritation or compression of the sciatic nerve past the piriformis musculus |
Diagnostic work-up for SIJ dysfunction may include imaging such as x-ray, magnetic resonance imaging (MRI), computed tomography (CT), and single-photon emission computed tomography (SPECT), which is a special type of CT browse. To confirm the SIJ is the pain generator, fluoroscopically-guided (via x-ray) injections into the joint can be performed. If business organisation for infection or an inflammatory or rheumatologic component such as sacroiliitis, additional lab work-up is indicated.
The Treatment Strategy
Once an underlying diagnosis of SIJ dysfunction has been made, the mainstay of handling is a comprehensive rehabilitation programme tailored to the runner. This should include a combination of relative rest or activeness modification and rehabilitation focused on strengthening, mobilization, and addressing the underlying issue, whether it'due south musculus imbalances, improper training, poor recovery, or even an anatomic issue such as a leg length difference. A biomechanical running evaluation may shed light on compensatory strategies that are overloading one or both joints and can help direct the rehab approach.
Sara Hall noted that while each instance is different, for her, the best class of cross grooming during her injury recovery has been the spin bike.
Manual therapy may play an adjunctive office in management of SIJ dysfunction, merely the treatment should be performed by an experienced sports specialist (i.eastward., sports osteopath, chiropractor, physical therapist, or athletic trainer) and should non be the sole treatment modality.
Depending on how severe and acute the pain is, a short form of non-steroidal anti-inflammatory drugs (NSAIDs) may help with hurting control. Therapeutic injections with corticosteroid into the SIJ may be beneficial if symptoms are refractory to more than conservative measures. Lastly, bracing may also be helpful in certain situations, for instance throughout pregnancy, but is not recommended for near cases.
Render to Running
If symptoms are mild, some athletes may be able to continue running with modifications, such as irresolute the terrain (less hills or less technical), reducing mileage, decreasing intensity, while also addressing the underlying issue(s) with a comprehensive rehabilitation approach (this is key ). If more severe, trying to "run through the pain" could exist detrimental and may lead to faulty movement patterns. In these cases, dedicating time to healing and rehabilitation is essential. Exact fourth dimension to return to running is quite variable and depends on the severity of pain and extent of underlying functional deficit.
Prevention
As far as prevention, start with preparation smarter, not harder. Respect the recovery. Avert drastic increases in running mileage, intensity, or change in terrain. And call up that training is more than than just running. Cadre, glute, and leg strengthening to stabilize the spine and pelvis tin can play a critical role in keeping runners healthy, happy, and injury-costless!
Disclaimer: This web log is for informational purposes only. Doctors cannot provide a diagnosis or individual treatment advice via due east-mail or online. Delight consult your doc almost your specific health care concerns.
References
- Peebles R, Jonas C E. 2017. Sacroiliac Joint Dysfunction in the Athlete: Diagnosis and Management. Current Sports Medicine Reports 16 (v): 336-342.
- Vanelderen P, Szadek Chiliad, Cohen SP, et al. 13. Sacroiliac joint pain. Pain Pract. 2010; 10:470Y8.]
- Geraci 1000 C, Brownish W. 2005. Evidence-based handling of hip and pelvic injuries in runners. Physical medicine and rehabilitation clinics of North America 16 (3): 711-747.
- Prather H. 2000. Pelvis and sacral dysfunction in sports and exercise. Physical medicine and rehabilitation clinics of North America 11 (4): 805-36, viii.
- Bruckner P, Khan M. Buttock Pain. In: Bruckner and Khan'south Clinical Sports Medicine. 4th ed. North Ryde (Australia): McGraw-Hill Australia Pty Ltd, 2012, p. 498Y502.
- Vasudevan J M, Smuck Chiliad, Fredericson M. 2012. Evaluation of the athlete with buttock pain. Current Sports Medicine Reports eleven (1): 35-42.
Source: https://www.athletebiz.us/blog/sacroiliac-si-joint-pain-and-dysfunction-in-runners-dr-emily-kraus/
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