천장관절의 생체역학 - 촉진 테크닉 그리고 논문 - 정리중...

[문형철]

요통의 15~25%는 si joint 문제임.

천장관절의 움직임은 rotation과 translation

천장관절은 전후방 회전이 평균 2.5도이고 평균 0.7mm까지 이동

The body's core stability starts in the pelvis so that the three levers-legs and vertebral column-can be moved safely!"

- 인체의 코어 안정성은 골반에서 시작하기 때문에 3개의 지레(2개 다리 그리고 척주)는 안정하게 이동함. 

The pelvic muscles have been strengthened and their endurance improved. This allows the body to economically maintain upright positions and ensures that standing on one foot is safe. The pelvis absorbs impulses arising from the legs and increases the range of hip-joint motion by rapidly transferring movement up into the lumbar spine.

- 골반근육은 강해져왔고 지구력은 증진되어옴. 

- 이는 인체가 선자세를 경제적으로 유지하게 하고, 한발서기가 안정되도록 함. 

- 골반은 하지에서 올라오는 충격을 흡수하고, 요추에서 움직임을 빠르게 전달함에 의해서 고관절 움직임이 증가함. 

panic bird...

- 천골은 장력 네트워크(tension network)의 허브축임. 

골반의 촉진법(클릭)

천장관절과 고관절의 해부학 동영상

천장관절의 해부와 생체역학 동영상

Palpation technique. 

9장 posterior pelvis

Significance and Function of the Pelvic Region

The pelvis is the kinetic and kinematic center of the musculoskeletal system. It is the center of the functional unit

of the lumbopelvic-hip (LPH) region. The kinematic chains of the vertebral column and the lower limbs meet

here. The pelvis must be able to withstand a variety of biomechanics demands, especially when the body is in upright position. 

- 골반은 근골격계 시스템의 운동학, 운동형상학의 중심.

- 요추골반고관절 복합체의 기능적 단위의 중심.

- 척주의 운동형상학적 사슬과 하지는 여기서 만남. 골반은 특히 선자세에서 다양한 생체역학적 요구를 견딜 수 있어야 함. 

Vleeming states (personal communication): 

"The body's core stability starts in the pelvis so that the three levers-legs and vertebral column-can be moved safely!"

- 인체의 코어 안정성은 골반에서 시작하기 때문에 3개의 지레(2개 다리 그리고 척주)는 안정하게 이동함. 

The pelvis has adapted itself to these demands throughout the phylogenetic evolution ( Fig. 9.1 ):

- 골반은 계통발생 진화과정의 요구사항에 적응함.

The large, protruding ala of the ilium provides a large area for the attachment of soft tissues and therefore the muscular prerequisites for an upright posture in standing: gluteal, back, and abdominal muscles. This protruding area of the ilia envelops and protects several organs.

- 장골의 날개부위는 크게 튀어나와 연부조직 부착부를 제공함. 

- 그래서 선자세를 위한 근육부착부를 만듬. 

The sacroiliac (SI) joint has increased greatly in size; the ligamentous apparatus has become considerably stronger. The load-transferring area between the SI joint and the acetabulum or the ischial tuberosities has been reduced in length and strengthened.

- 천장관절은 크기가 커져감에 따라 인대구조는 더욱 단단해짐.  

- 천장관절과 관골구사이 또는 좌골결절의 부하전달 부위는 길이가 줄어들고 강해짐.

The sacrum has remained in the same position in the sagittal plane, tilting inward toward the abdominal cavity. This allows lumbar lordosis and enhances shock absorption. Ligaments stabilize the sacrum's position. 

- 천골은 시상면에서 같은 위치로 남아 복강쪽으로 기울어져 있음. 

- 이것은 요추 전만을 허용하고 충격흡수능력을 증진시킴. 

- 인대는 천골 위치를 안정화시킴. 

Mobility in the SI joint is related to age and gender. The range of motion is governed by hormones, among other things, in females. Pelvic movement enables the birth canal to dynamically adapt during delivery. The increase in hip-joint mobility, especially in extension, is also the result of phylogenetic development. The femoral head is integrated into the body's plumb line. During walking, the trochanter point is transported forward during the mid-stance phase.

- 천장관절에서 움직임은 나이, 성별과 연관되어 있음. 

- 여성에서 움직임 범위는 호르몬에 의해 지배됨. 

- 골반은 출산 동안 많이 움직일 수 있음. 고관절 운동성 증진은 계통발생의 결과에 의함. 대퇴골두는 인체의 추선에 조화를 이룸. 

- 보행동안 대전자는 mid stance 동안 앞으로 이동함. 

The pelvic muscles have been strengthened and their endurance improved. This allows the body to economically maintain upright positions and ensures that standing on one foot is safe. The pelvis absorbs impulses arising from the legs and increases the range of hip-joint motion by rapidly transferring movement up into the lumbar spine.

- 골반근육은 강해져왔고 지구력은 증진되어옴. 

- 이는 인체가 선자세를 경제적으로 유지하게 하고, 한발서기가 안정되도록 함. 

- 골반은 하지에서 올라오는 충격을 흡수하고, 요추에서 움직임을 빠르게 전달함에 의해서 고관절 움직임이 증가함. 

In total, the phylogenetic adaptations are a good example of morphological and functional adaptation in the entire musculoskeletal system. These adaptations are shaped significantly by three aspects:

- 정리하면 계통발생 진화에 적응함은 전체 근골격계 시스템에서 형태학적, 기능적 적응의 좋은 사례임. 

- 세가지 측면에서 적응함. 

• Bipedal locomotion. 두발로 걸어 이동함. 

• Grasping function of the hands. 손으로 쥐는 기능. 

• Spatial adjustment of the head. 머리의 공간 적용 조절. 

Common Applications for Treatment in this Region

The pelvis is frequently the focus of treatment for symptoms in the LPH region (lumbar spine, pelvis, hip) due to the intensive strain that the pelvis experiences during different tasks. Therapists have a special task when assessing patients: to find out why the patient is suffering from pain in the buttocks or the groin.

- 골반은 흔히 요추골반고관절 복합체에서 나타나는 증상치료에 초점이 됨. 다양한 일을 하는 동안 골반에 과도한 응력이 가해짐때문에..

- 치료사는 환자 진단할때 특별한 방법을 가짐. 왜  환자가 엉덩이 서혜부에 통증을 호소하는가를 발견하기 위해. 

The following structures possibly generate pain (tissues that cause pain): 

- 골반 통증 요인들

• Lumbar or inferior thoracic structures - 요추 또는 하부 흉추구조

• The Sl joints and their ligaments - 천장관절과 인대

• Structures in the hip joint - 고관절 구조

• Nerves in the gluteal region - 엉덩이 근육들

• Muscular components - 근육

The last can be a primary or secondary source of pain and appear tensed and tender to touch. Also, various internal organs are represented in the Head zones located in the skin of the gluteal region. 

- 골반 근육은 골반통증의 첫번째 또는 두번째 요소임. 그리고 긴장할 수 있고, 만질 수 있음. 또한 다양한 내장기관은 엉덩이 안쪽에 위치함.

Certain assessment techniques and forms of treatment are thus applied to the gluteal region. Apparently, over 50 provocation and mobility tests have been described for the Sl joint at an international level. Each study group for manual therapy uses their own individual test. International standardization is not yet foreseeable. 

- 골반에 다양한 진단 테크닉과 치료법이 존재함. 

- 50가지가 넘는 악화 그리고 움직임 테스트가 존재함. 

When these tests are being conducted or the patient is being mobilize, it frequently makes sense that certain osseous reference points (iliac crests. anterior and posterior iliac spines) are palpated accurately and their position compared with the other side (Fig. 9.2). 

- 이러한 검사가 시행될때 뼈 기준점(장골근, ASIS, PSIS)은 정확하게 촉진되고, 그들의 위치는 양측으로 정확하게 비교해야 함. 

The sacrum and the ilium are often mobilized in opposite directions during assessment and treatment (Fig. 9.3).

- 천장관절 가동법

It is very important that the hand position is well placed and secure. Some peripheral nerves can be irritated locally as they pass through the gluteal region on their way to their target organ. In the case of the sciatic nerve. this can occur at two locations (Fig. 9.4):

좌골신경은 이상근 아래, 햄스트링 아래 두부위에서 압박될 수 있으므로 주의해서  촉진해야...

• Compression neuropathies caused by an extremely tense piriformis (the piriformis syndrome).

• Friction at the ischial tuberosity and the hamstrings tendon of origin (the hamstrings syndrome).

참고) Entrapment of the proximal sciatic nerve by the hamstring tendons

Entrapment of the proximal sciatic nerve by the hamstring tendons.pdf

These problems can be confirmed using an accurate and detailed palpation with the application of pressure. A piriformis compression syndrome occurs only when at least a portion of the sciatic nerve passes through the muscle belly of the piriformis. According to Vleeming. the fibular part passes through the piriformis muscle belly in only 4%-1 0% of all people (Fig. 9.5). 

- 이상근 증후군은 좌골신경이 두분지로 나뉘어 근육사이로 지나올때 발생.. 4-10%정도 변이가 있음.

- 좌골신경의 두 분지는 fibular part(peroneal part)와 tiabial part

A sustained muscle contraction alone is not expected to compress the nerve as the muscle is smooth and fibrous on the side facing  the nerve. Also, the 4 cm-long muscle belly cannot expand so much during contraction that it compromises or stretches the nerve.

- 근육은 부드럽고, 신경과 마주한 부위의 섬유때문에 지속적인 근수축만으로는 근육아래의 신경을 압박할 수 없음. 

- 4cm길이 근복은 수축하는 동안 그렇게 많이 확장하지 않음. 

The trigger-point treatment, based on the work of Traveil and Simons ( 1998), is concerned with the localization

of locally hardened muscles that may act as independent pain generators. Dvorak also dealt with the subject of tender

points within manual diagnostics. These points provide the clinician with information regarding the spinal level of sacroiliac and lumbar aggravation (Dvorak, 2008).

- 발통점 치료는 독립적으로 통증요인이 될 수 있는 국소적으로 단단해진 근육의 국소화와 연관됨. 

Dvorak labeled tender points as tendinoses and zones of irritation. Local in vivo anatomy is used here to find the appropriate muscular structure or to link the point that is tender on palpation to its respective muscle. Muscle pathologies are treated using classical massage techniques, such as kneading (Fig. 9.6), local frictions (Fig. 9.7), or a variety of specialized techniques. These techniques can be conducted more accurately when the therapist has a good knowledge of the available area and can correctly feel the muscular structure being sought. Precise palpation is also used to confirm‎ bursitis by applying local and direct pressure (Fig. 9.8) (e.g., when presented with a type of snapping hip) or to perceive muscle activity in the pelvic floor directly medial to the ischial tuberosity (Fig. 9.9). 

- 근육질병은 고전적인 마사지 테크닉 "kneading, local friction, 다양한 특수화된 테크닉"으로 치료

- 이러한 테크닉은 치료사가 근육구조를 정확하게 알때 정확하게 시행할 수 있음. 

- 정확한 촉진은 또한 좌골점액낭염 등을 진단할 수 있음. 

Required Basic Anatomical and Biomechanical Knowledge

The pelvis is the anatomical and functional center of the "lumbopelvic region." Two movement complexes meet at the sacrum: the vertebral column and the pelvis. This means that vertebral movement is directly transmitted onto the pelvis, and vice versa. 

- 골반은 요추-골반부위의 해부학적, 기능적 중심임. 

- 두가지 움직임 복합체가 천골에서 만남. 척주와 골반. 이 말은 척추의 움직임이 골반에 직접적으로 전달된다는 의미. 역의 개념도 성립함. 

Several points on the pelvis are of static and dynamic significance: the base of the sacrum, iliac crest, SI joint, pubic symphysis, and the ischial tuberosity. The different types of loading are dealt with here, for example, by transferring the load in sitting or standing. Important ligamental structures and muscles insert here.

- 골반에 몇가지 정적, 동적 중요성 포인트가 있음. 천골의 기저부, 장골릉, 천장관절, 치골결합, 좌골..

- 서로다른 형태의 부하가 여기에서 처리됨. 예를들어 앉기 또는 서기 부하의 전달 등. 중요한 인대 구조와 근육이 이부위에 부착함. 

Surprisingly, anatomical literature does not always agree on the bony compilation of the pelvis. Netter (2004) only includes the two pelvic bones. In total, the pelvis should be understood to be a bony ring consisting of three large parts: two pelvic bones (consisting of the ilium, ischium, and pubis) and the sacrum (Fig. 9.10).

- 놀랍게도, 해부학 문헌에는 골반의 뼈구조에 일치되는 의견이 없음. 

- 장골, 좌골, 치골로 구성된 두개의 골반뼈와 천골이 존재. 

The different parts are joined together by mobile and immobile bony connections:

- 움직이는 뼈와 움직이지 않는 뼈의 연결에 의해서 두개의 다른 부분이 연결됨.

• Mobile: two SI joints and the pubic symphysis. 

• Immobile: Y-formed synostosis in the acetabulum as well as a synostosis between the ischial ramus and the inferior pubic ramus, the bony connection between the originally distinct sacral vertebrae at the transverse ridges.

- 움직이는 부분 : 두개의 천자관절과 치골결합(pubic symphysis)

- 움직이지 않는 부분 : 관골구, 좌골가지, 하부 치골가지...

The mobile connections allow a certain amount of flexibility in the pelvis, absorbing the dynamic impulses coming from a superior or inferior direction. Shock absorption is an important principle for the lower limbs and is continued in the pelvis. This flexibility also creates a gradual transition from the more rigid pelvic structures to the mobile lumbar segments.

- 움직이는 연결은 골반에서 많은 유연성, 위쪽 또는 아래쪽 방향으로부터 오는 동적 충격 흡수를 허용함. 

- 충격흡수는 하지를 위한 중요한 원리임. 

- 이러한 유연성은 움직이는 요추분절에 단단한 골반구조로 전달되는 점차적인 이동을 만듬. 

Gender-based Differences

골반의 남녀차이

The gender-specific characteristics of the pelvis are presented in almost every anatomy book. In summary, these characteristics are based on the difference in form and are most distinctly seen in the ala of the ilium and the ischial

tuberosities. In total, the male pelvis is described as being long and slender and the female pelvis as being wider and shorter. The dimensions of the female pelvis are therefore seen as a phylogenetic adaptation to the requirements of

the birth canal during child birth.

- 골반의 성별특성은 거의 모든 책에 언급됨. 

- 정리해보면... 남녀 골반의 차이는 장골의 날개와 치골결합에서 분명한 형태차이를 가짐. 

- 남자의 골반은 길고 가는 구조이고, 여자의 골반은 넓고 짧음. 

- 여성 골반의 수치가 이렇게 변한 것은 출산동안 산도의 필요성에 계통발생적 적응이 필요했기 때문. 

The differences in detail:

• The alae of the ilia are higher and more slender in the male pelvis.

• The inner pelvic ring, the level of the pelvic inlet, or the arcuate line tend to be rounder in the male pelvis and more transversely elliptical in the female pelvis.

• The two inferior pubic rami form an arch (pubic arch) in the female pelvis. It has been described as more of an angle (pubic angle) in the male pelvis.

Naturally, these different characteristics in the bony anatomy of the pelvis also have a meaning for local in vivo  anatomy. They determine what is to be expected topographically when searching for a specific structure (Fig. 9.1 1 ) :

• The iliac crests are readily used for quick orientation in the lumbar area. The most superior aspect of the iliac crest is found higher up in males than in females:

- 장골능은 요추부위에서 차이가 있음. 장골능의 윗부분은 여성보다 남성에서 위에서 관찰됨. 

- Males: mostly between the L3 and L4 spinous processes.

- Females: mostly at the level of the L4 spinous process.

• As with the iliac crests, the anterior superior iliac spine (ASIS) is preferably located to determine levels within the pelvis. It can be assumed that the female ASISs are found significantly further apart than their male counterpart. Therefore, it is necessary to search for them more laterally.

- 장골능을 보면, 여성의 전상장골극은 남성보다 훨씬 바깥쪽에 위치함. 

• The inferior pubic rami meet at a significantly smaller angle in the male pelvis. It is therefore expected that the ischial tuberosities can be palpated significantly more medially in the male pelvis than in the female pelvis. 

- 아래쪽 치골가지는 남성골반에서 훨씬 좁은 각도를 가짐. 

- 좌골결절은 여성보다 남성에서 훨씬 내측에서 촉진할 수 있음. 

Coxal Bone

The coxal bone is the largest fused bony entity in the musculoskeletal system once skeletal growth has been completed.

Two surfaces extend superiorly and inferiorly from a central collection of bony mass in the acetabular area:

- Coxal bone는 가장 큰 융합된 뼈. 

- 관골구에서 뼈의 중심모음까지 위아래로 연장된 구조. 

# Superior surface = ala of the ilium. This surface is entirely osseous. Its borders are strengthened by strong edges and projections (iliac crest and diverse spines). Although the middle of the ala of the ilium is osseous as well, it tends to be thinner and can be perforated in some cases.

# Inferior surface = the rami of the ischium and the pubis with a central collagen plate (obturator membrane).

When planes are drawn at a tangent over these superior and inferior surfaces, these planes are seen to be found at a 90° angle to each other (Fig. 9.12).

The protruding edges, spines, and flattened areas of both surfaces of the coxal bone act as possible sites of origin or insertion for muscles and ligaments. Anatomical specimens show that the ilium is almost completely enclosed by the small gluteal muscles and the iliacus. The obturator membrane is likewise located between the obturator extern us and the obturator intern us. Thus, a series of active dynamic forces act on the coxal bone. 

- coxal bone의 protruding edge, spines and flattened area 양측면은 근육과 인대를 위한 기시, 종지의 면으로 작용함. 

- 장골은 장골근과 둔부근육에 의해서 둘러싸여 있음. 

Other sections with significantly spongy thickening (Fig. 9.13) can be identified in addition to the previously mentioned bony bracing at the edge of both coxal bones and the central bony mass: 

• The body's weight in standing is transferred from the SI joint to the acetabulum and vice versa along the arcuate line. The arcuate line divides the greater lesser pelvis(1).

- 선자세에서 체중은 천장관절을 통해 관골구로 전달됨. 그 역도 성립함. 

• Weight is transferred in sitting between the SI joint and the ischial tuberosity (2).

- 체중은 앉은 자세에서 천장관절과 좌골사이로 전달됨. 

• Pressure and tensile stresses are transmitted from the coxal bone onto the symphysis via the superior pubic ramus (3).

- 압력과 장력은 coxal bone로부터 치골결합으로 전달됨. 

The weight of the body is transferred from the vertebral column onto the pelvis at the SI joint. This is approximately 60% of the entire body weight in an upright position.

- 체중은 척추로부터 골반, 천장관절로 전달됨. 선자세에서 전체 체중의 대략 60%임. 

Sacrum

천골면에 부착하는 이상근과 장골근 부착부 위치를 보자.

천골후면에 부착하는 다열근, 광배근, 대둔근 등의 부착부를 보자.

대둔근은 장골에 넓게 부착함. 

천골결절, 천장관절면, Median sacral crest, coccyx 등을 보자. 

천골을 위에서 바라본 그림 - sacral canal, articular process, sacrum의 ala

The sacrum is the third and central part of the bony pelvis. It is well known that the sacrum is a fusion of at least five

originally distinct vertebrae. The final ossification into a single bone occurs in the fifth decade of life. Remnants

of cartilaginous disks are existent prior to this.

- 천골은 골반의 중심부에 위치함. 

- 천골의 완전한 골화는 50대에 일어남. 

Location and Position

The location and position of the vertebral column's kyphotic section at the pelvis can be identified in the median cut of the pelvis. The recognizable tilt of the sacrum into the pelvic space can be calculated by using the angle between the transverse plane and a line extending from  the end plate of SI (Kapandji, 2006). This generally amounts to approximately 30° (Fig. 9. 1 4).

- 골반에서 척주의 후만이 골반중심부 단면을 보면 확인됨. 

- 아래그림과 같은 천골각이 중요한데 30도가 정상임. 

The sacrum's position has several consequences:

• It is the foundation for the lumbar lordosis and therefore the double "S" seen in the vertebral column.

- 요추 전만과 천골의 후만을 연결하면 S자형의 구조.

• The tip of the sacrum points posteriorly and enlarges the inferior section of the birth canal.

- 천골끝은 산도의 아래단면까지 확장됨.

• Vertical loading in the upright position is transformed less into translational movement and more into rotational

movement (tendency to nutate). This is absorbed by the ligamentous apparatus. 

- 선자세에서 수직부하는 이동움직임과 회전움직임을 전달함. 이는 인대구조에 의해서 충격이 흡수됨. 

The sacrum's distinctive form becomes evident in the posterior view (Fig. 9.1 5). It is characterized by various structures:

• The S1 end plate (base of the sacrum).

• The sides of the sacrum:

- S1 to S3 ; auricular surface and the sacral tuberosities (neither are palpable) 

- S3 to S5 ; edge of the sacrum (palpable).

- 천골의 옆면을 보면 s1-s3은 천장관절을 이루고, s3-5은 천골의 edge를 만들어 촉진가능함. 

• The connection between the inferolateral angles.

It is now apparent that the sacrum is not triangular in shape but rather trapezoid.

- 천골은 삼각형이 아니라 마름모꼴에 가까움. 

Detailed Anatomy

The posterior aspect demonstrates additional interesting details (Fig. 9.1 6) :

#  SI has not only received the vertebral body end plate, but also the superior articular processes. These form

the most inferior vertebral joints with L5.

- 천골 1번은 척추와 연결될 뿐아니라 후관절로 연결됨. 

# Generally, it is possible to look through the bony model in four places on each side. The sacral foramina are found posteriorly and anteriorly at the same level and allow the anterior rami and the posterior rami of the spinal nerves to exit from the vertebral column and into the periphery.

- 천골공(sacral foramina)은 같은 레벨에서 전후면이 발견됨. 척추신경의 전후면 가지가 나옴. 

# Long ridges are found over the entire remaining posterior surface. These ridges are formed by the rudiments of the sacral vertebrae that have grown together. The median sacral crest is the most important of these ridges for palpation. The rudiments of the sacral spinous processes can be seen here as irregular protrusions and can be palpated well. All other crests and the posterior foraminae are hidden under thick fascia and the multifidus muscle.

- 중앙 천골능은 촉진을 위한 중요한 부위. 

- 다열근이 부착하는 부위 살피기

Apex of the Sacrum and the Coccyx

The apex of the sacrum forms the sacrum's inferior border. It lies in the middle, slightly inferior to the line connecting

the two inferolateral angles. The mobile connection to the coccyx is found here. This is interchangeably labeled a synovial joint or a synchondrosis (with the intervertebral disk) in literature (Fig. 9.1 7). 

- 천골의 끝, coccyx

Great variations are seen in the construction of the inferior sacral area. The median sacral crest usually runs down to the level of S4. Normally no rudiments of the spinous processes can be observed at the S5 level. Instead, an osseous cleft can be seen: the sacral hiatus. According to Lanz and Wachsmuth ( 2004a), this posterior cleft is only found in approximately 46% of the population at the level of S5 and extends to the level of S4 or S3 in 33.5%. 

- 하부 천골은 다양한 변이가 존재함. 

- 중앙 천골능은 s4까지 아래로 내려감. 

- 천골끝에는 천골열공(sacral hiatus)가 발견됨. 

This makes accurate palpatory orientation on the inferior sacrum significantly more difficult. The S5 arch leading to the hiatus is incomplete and is covered by a membrane (Fig. 9.1 8). Small osseous horns (sacral horns) form its borders on the side. These horns are easily palpable in most cases, but vary greatly in size and are irregularly shaped. They face two small osseous protrusions in the coccygeal bone, the coccygeal cornua,which are also palpable.

- 꼬리뼈는 촉진가능함. 

The covering membrane at the level of s5 is a continuation of the supraspinous ligament and continues onto the coccyx as the superficial posterior sacrococcygeal ligament. The membrane covers the vertebral canal as it peters out inferiorly. It is palpated as a firm and elastic structure, which clearly distinguishes it from the osseous borders. Additional ligamentous connections between the sacrum and coccyx are (Fig. 9.1 9): 

- 천골 5번까지 극상인대가 연결되어 있음. 

- 전골과 coccyx사이의 인대연결이 있음. 그림 참조..

• The deep posterior sacrococcygeal ligament, the continuation of the posterior longitudinal ligament.

• The lateral sacrococcygeal ligament (intercornual and lateral sections), presumably continuations of the former ligamenta flava and the intertransverse ligament.

- 심부 후면 sacrococcygeal ligament는 꼬리며 중앙에 위치

- 외척 sacrococcygeal ligament는 위그림과 같이 두개가 존재함. 

These ligamentous structures are traumatically overstretched when people fall onto their buttocks and especially onto the coccyx. Their tenderness on pressure can be treated successfully using transverse frictions to relieve pain when they are directly palpated.

- 꼬리뼈의 인대구조는  엉덩방아와 같은 타박손상에서 늘어날 수 있음. 압박시 통증은 직접적으로 촉진하여 교차마찰마사지를 시행하면 성공적으로 치료할 수 있음. 

The Pelvic ligaments

The ligaments of the pelvis can be classified according to their position and function. We are therefore familiar with ligaments that:

- 골반의 인대는 그들의 위치와 기능에 따라 분류할수 있음. 

• act to maintain contact between the surfaces of the s1 joint:

- interosseous sacroiliac ligaments, located directly posterior to the s1 joints;

- 요추 5-천골 1번을 연결하는 장요인대

• restrict nutation and therefore stabilize the sacrum:

- anterior sacroiliac ligaments (reinforce the capsule);

- posterior sacroiliac ligaments;

- sacrotuberous ligament;

- sacrospinous ligament;

- 천골의 nutation을 제한하고 안정화시키는 전천장인대, 후천장인대, 천조인대, 천극인대

• can limit counternutation:

- long posterior sacroiliac ligament.

- 천골의 counternutation을 제한하는 장후천장인대

The anterior sections of the capsule (anterior sacroiliac ligaments) are very thin ( 1 mm이하 ) and have little mechanical relevance (personal correspondence from the IAOM study group). They perforate easily when joint pressure is increased (arthritis). They are not stretched during the iliac posterior test (s1 joint test) as the entire function of the ligament is found posterior to the joint.

- 천장관절낭의 전방 단면은 매우 얇은 1mm이하. 그리고 매우 작은 역학적 중요성을 가짐. 

- 그것은 관절압력이 증가할때 쉽게 천공됨. ....

The interosseus ligaments are very short, nociceptively supplied ligaments that act as pain generators in the presence

of sacroiliac pathologies (e.g., instability or blockages). Their function is to maintain the traction in the respective s1 joint.

It is easiest to understand the function of the nutation restrictors by looking at the stress on the sacrospinous and sacrotuberous ligaments when the body is in a vertical position (Fig. 9.20). 

- 뼈사이의 인대는 매우 짧고, 통증이 있는 인대임. 그래서 천장관절 질병이 발생할때 통증 발원처로 작용함. 

- 천조인대와 천극인대에 장력부하가 주어지는 직립으로 선자세에서 nutation을 제한하는 기능을 함. 

Approximately 60% of the body's weight bears down on the S1 end plate. This is positioned quite anterior to the nutation/counternutation axis so that the base of the sacrum tends to "fall" farther into the pelvic space. This tendency is counteracted by the posterior and anterior ligaments positioned very close to the joint. The tip of the sacrum tends to lever itself anteriorly and superiorly. This movement is counteracted by the sacrospinous and sacrotuberous ligaments. 

- 천골 1번 종판에 대략 60%의 체중부하가 주어짐. 

- 천골의 nutation/counternutation축..

- 천극인대와 천조인대에 의해서 움직임에 제한됨을 이해해야

The long posterior sacroiliac ligament (Fig. 9.21 ) connects both posterior superior iliac spines (PSISs) with the respective edge of the sacrum. It is approximately 3- 4 cm long, 1 -2 cm wide, and extends inferiorly into the sacrotuberous ligament. It is the only ligament that counteracts counternutation. It has been described by Vleeming ( 1 996) and already published several times. It has also been mentioned by Dvorak (2008).

- 장후천장인대는 PSIS와 천골을 뒤에서 이어주는 인대. 

- 길이는 대략 3-4cm, 넓이는 1-2cm, 아래쪽으로 천조인대까지 연결됨. 

- 장후 천장인대는 천골의 counternutation(???)에 반대로 작용하는 유일한 인대. 

The fibers of the multifidus muscle are noticeable as they extend medially into the ligament. A section of the ligament

arises from the gluteus maximus on the lateral side.

The Sacroiliac Joint

The significance of the pelvis as central element in the musculoskeletal system has already been described. To understand the exceptional significance of the SI joint, the functional relationship between the various kinematic chains should first be clarified.

- 천장관절의 중요성을 이해하기 위해서, 다양한 운동형상학 사슬을 잘 이해해야 함. 

First Kinematic Chain: The Sacrum as Part of the Vertebral Column

- 첫번째 운동 사슬 기능 : 천골이 척주의 일부로서 작용.

The L5, sacrum, and ilium form a kinematic chain. No bone moves without the others moving. It is nearly impossible to clearly attribute the effects of pathology and treatment to a specific level. The iliolumbar ligaments (especially the inferior short, stiff sections) are important for the linkages within this chain.

- 요추 5, 천골, 장골은 운동형상학 사슬을 형성함. 

- 다른 움직임 없이 뼈 단독으로 움직이지 못함. 

- 장요인대는 이 사슬내에서 가장 중요한 연결구조물. 

Second Kinematic Chain: The Sacrum as Part of the Lower Limbs

- 두번째, 운동사슬 : 천골이 하지의 일부로서 작용

The largest SI joint movements occur when the hip joints are included in the movement symmetrically and without

loading, such as is the case during hip flexion in supine position.

- 가장 큰 천장관절 움직임이 고관절 움직임이 대칭적으로, 열린사슬에서 고관절 굴곡동안 발생함. 

Third Kinematic Chain: The Sacrum as Part of the Pelvic Ring

- 세번째, 운동사슬 : 천장관절이 골반 링의 일부로서 작용.

The SI joint biomechanics are controlled by the symphysis. Extensive, opposing movements of the iliac bones primarily

meet up at the symphysis. SI joint instability can also affect the symphysis. We therefore differentiate the SI joint instability types into those without loosening of the symphysis and those with loosening of the symphysis. 

- 천장관절 생체역학은 유합에 의해서 조절됨. 

- 천장관절 불안정성은 유합에 영향을 줌. 그래서 천장관절 불안정성 분류의 2가지 형태가 있음. 유합에 loosening이 있는가 없는가?

Few topics concerning the musculoskeletal system are discussed as controversially as the SI joint. Views and opinions

about the SI joint vary between the individual manual therapy study groups as well as between manual therapists and osteopaths. The significance given to the SI joint therefore depends on each therapist's personal criteria and individual point of view. 

- 몇가지 근골격계와 관련된 주제가 토론되어야 

Reasons for the Differences in Opinion about the SI Joint

Special Anatomical Factors

The construction of this joint cannot be compared with any "traditional" joint (Fig. 9.22):

• It is a firm joint (amphiarthrosis) anteriorly and connects the bones posteriorly via a ligamentous structure (syndesmosis ).

• The joint surfaces are curved at all levels and have ridges and grooves.

• The sacral joint surface is very thick, the iliacal surface extremely rough. 

SI Behavior during Movement

- 움직임동안 천장관절의 생체역학

# The sacrum and the ilium always move against each other in a three-dimensional manner.

- 천골과 장골은 항상 3차원 공간에서 서로 대항하며 움직임. 

# Describing the position of the axes during these movements is extremely complicated. 

- 천장관절 움직임 동안 묘사하는 축의 위치는 매우 복잡함. 

#  Movement primarily occurs around a frontotransversal (transversal) axis and is very slight (according to Goode [2008J, approximately a maximum of 2°). These movements are labeled nutation and counternutation (Fig. 9.23). Women affected by hormones are particularly subject to movement here (Brooke, 1 924, and Sashin, 1 930). Mobility also increases when SI joint disorders are present, for example, with arthritis.

- 움직임은 전횡축주위로 일어나고 매우 조금 일어나는데, 대략 2도 움직임. 

- 여성은 호르몬에 의해서 지배를 받아 움직임이 더 잘 일어남.

- 천장관절 질환(관절염)이 있을때 움직임은 증가함. 

# The male SI joint starts to become immobile from around age 50 due to the formation of osseous bridges (Brooke, 1 924 and Stewart, 1 984).

- 남성 천장관절은 50대에 좀더 덜 움직임. 이유는 osseous bridge의 형성때문에

The complexity of this joint also makes it easy to understand why comparatively few good studies exist that examine

standardized assessment methods and treatment techniques. More than 50 tests have been described for assessment alone. 

- 천장관절의 복잡성은 ....

Sacroiliac Joint Biomechanics

The SI joint is held together by its structure and the strength of tissues. This can be seen in the frontal plane by looking at the general alignment of the joint surfaces. According to Winkel (1992) the joint surfaces are tilted at approximately 25° from the vertical (Fig. 9.24).

- 천장관절은 그것의 구조와 조직의 강도에 의해서 고정됨. 

- 수직면과 천장관절면이 이루는 각도는 대략 25도임. 

The sacrum's wedge shape permits the auricular surface to support itself on the similarly shaped iliacal joint

surface (force closure). Nevertheless, the joint's construction and the friction coefficient of the uneven and roughened surface are not sufficient to stabilize the sacrum's position.

- 천골의 쐐기모양 형태는 관절면을 제공하고 장골면과 관절하여 Force closure로 지지됨. 

- 그럼에도 불구하고, 관절 구조와 마찰계수는 편평하지 않고 거친면이어서 안정성을 만드는데 충분치 않음. 

It therefore becomes clear that additional strength is needed to keep the joint surfaces together (holding the joint together with the strength of tissues). In particular, this is the function of the interosseous sacroiliac ligaments. These ligaments lie immediately posterior to the joint surfaces and are made of short, very strong, and nociceptively

innervated collagen fibers. The SI joint is held together more by the joint structure in males and the strength of tissues in females.

- 그래서 추가적인 힘이 관절면을 서로 고정하는데 필요함. 특히 천장인대가 그 기능을 함. 

- 천장인대는 천장관절의 후면에 자리하고, 짧고 강하게 만들어짐. 통각수용기가 많은 콜라겐 섬유로 만들어짐. 

- 천장관절은 남성의 경우 관절구조에 의해서 고정되고, 여성에서 조직의 강도로 고정함(??)

The interosseous ligaments are supported by muscular structures and other ligamentous structures that generally act as nutation restrictors. These structures therefore qualify as further SI joint stabilizers:

- 골간 인대는 근육조직에 의해서 지지되고, 다른 인대구조는 Nutation 제한구조로 작용함. 

• The anterior abdominal muscles (especially the oblique and transverse sections) pull on the ilia anteriorly and place the interosseous ligaments under tension(Fig. 9.25).

- 전면의 복부근육은 장골을 앞쪽으로 당겨, 장력하의 골간인대를 둠.

• The complex thoracolumbar fascia is considered an important stabilizer of the lumbosacral region (Vleeming, 1995).

- 복잡한 흉요근막은 요천추부위에 중요한 안정화 구조물임. 

• The multifidus acts as a hydrodynamic strengthener. Its swelling during contraction tightens the thoracolumbar fascia.

- 다열근은 유체역학적 힘구조물로 작용함. 흉요근막과 함께 작용...

• The gluteus maximus originates on the posterior surface of the sacrum. The superficial fibers cross over the SI joint and likewise radiate into the thoracolumbar fascia.

- 대둔근은 천골의 후면에서 기시함. 천장관절을 가로지르는 천층 섬유와 흉요근으로 방사되는 ....

• The piriformis originates on the anterior surface of the sacrum. It crosses over the  joint.

- 이상근은 천골의 전면에서 기히하여 천장관절을 가로지름. 

• The pelvic floor muscles, for example, coccyges and levator ani exert their force onto the posterior pelvis.

- 골반저 근육은 ....

• The posterior and anterior sacroiliac ligaments, together with the sacrospinous and sacrotuberous ligaments, primarily restrict the nutation of the sacrum. Loading tightens these ligaments and likewise increases the compression of the SI joint. 

- - 후, 전방 천장인대는 천극인대와 천조인대 함께 작용하여 천골의 Nutation제한자로 작용함. 이 인대에 부하가 주어지면 천장관절에 압박력이 증가함. 

• Several sections of the iliolumbar ligaments cross over the SI joint in the middle. Lumbar lordosis increases the SI joint surface compression (Fig. 9.26).

- 장요인대의 여러 단면은 ...

Pool-Goudzwaard et al. (200 1 ) described in a study the stabilizing role of the iliolumbar ligaments on the SI joint. Gradual transection of the ligaments resulted in a significant increase in SI joint mobility in the sagittal plane.

- 장요인대의 안정성 역할에 대한 탐구

The ligaments also contribute to sacroiliac movements being transmitted onto the lower lumbar segments and vice versa. Movement within the pelvic ring and movement in L4-51 must always be regarded as a kinematic chain.

- 인대는 또한 천장관절 움직임에 공헌함.. 

- 골반링과 요추 4-5번 움직임은 항상 운동형상한 사슬로 간주되어야 함. 

The dominating concept until several years ago was that the SI joint, as a classic amphiarthrosis, was not supplied with its

own muscles. This presumption is correct as regards the mobility function. However. it con be put on record that force

closure, in the form of a multitude of dynamited ligaments and muscles, holds the joint surfaces together and stabilizes

the SI joint.

Ligament Dynamization in the Sacroiliac Joint

The interplay between muscles and ligaments near joints has been known for a long time now. The knee joint is a perfect example of this. The extension of muscles into capsular-ligamentous structures is called ligament dynamization.

Two examples of pelvic ligaments are presented here to demonstrate how intensive the contact is between muscles and the functional collagen in this region.

- 천장관절 주위의 근육과 인대의 상호작용은 오래전부터 알려짐. 무릎관절은 완벽한 예. 

- 관절낭-인대구조에서 근육의 신전은 인대 dynamization이라고 부름.

Sacrotuberous ligament

The sacrotuberous ligament is connected to the:

• Gluteus maximus from a posterior direction.

• Biceps femoris from an inferior direction.

• Piriformis from an anterior direction.

• Coccygeus from a medial direction. 

Vleeming (1995) explains the functional significance of the sacrotuberous ligament, dynamized by the biceps femoris, on the SI joint as follows:

- 천조인대의 기능적 중요성, 대퇴이두근에 의해서 활성화되는 ...

We know that the hamstring muscles are most active at the end of the swing phase during gait. The hamstrings slow down the anterior tibial swing a few milliseconds before heel contact, decelerating knee extension. The long head of the tensed biceps femoris often merges with the sacrotuberous ligament via large bundles of collagen (also without contact with the ischial tuberosity) and dynamizes the ligament (Fig. 9.27). The biceps femoris activity prevents the sacrum from fully nutating and stabilizes the SI joint directly before the landing phase.

- 햄스트링은 보행 유각기 끝에서 가장 활성화되는 근육. 

- 햄스트링은 

Thoracolumbar Fascia

The thoracolumbar fascia consists of three layers:

• Superficial layer-posterior layer.

• Middle layer-inserted on the lumbar transverse processes.

• Deep layer-anterior layer found anterior to quadratus lumborum and iliopsoas.

The posterior, superficial layer contains collagen fibers arising from several muscles that can tighten up this aponeurosis:

• Latissimus dorsi.

• Erector spinae.

• Gluteus maximus. 

Each of the muscles is able to dynamize the fascia. The fascia forms a diagonal sling between the latissimus dorsi and the contralateral gluteus maximus (Fig. 9.28). The force of the sling acts perpendicular to the joint surfaces, stabilizing the SI joint and the inferior lumbar spine during strong rotation. Consequently, the participating muscles and the fascia belong to the primary SI joint stabilizers. This sling can be especially trained using trunk rotation against resistance.

This fascial layer is also connected to the supraspinous ligament and the interspinous ligament up to the ligamentum flava. Vleeming (personal communication) commentson this: "The entire system is dynamically stabilized."

Muscles also dynamize the middle and deep layers. It is well known that the transversus abdominis tightens the middle layer (see also the section "Detailed Anatomy of the Ligaments," in Chapter 1 0, p. 248).

The required background information on the pelvic muscles is given in the section "Palpatory Procedure for

Quick Orientation on the Muscles" below, page 2 1 4.

Sacroiliac Joint Pain. 리뷰논문.pdf

Sacroiliac (SI) joint pain is a challenging condition affecting 15% to 25% of patients with axial low back pain, for which there is no standard long-term treatment. Recent studies have demonstrated that historical and physical examination findings and radiological imaging are insufficient to diagnose SI joint pain. The most commonly used method to diagnose the SI joint as a pain generator is with small-volume local anesthetic blocks, although the validity of this practice remains unproven. In the present review I provide a comprehensive review of the anatomy, function, and mechanisms of injury of the SI joint, along with a systematic assessment of its diagnosis and treatment.

- 천장관절 통증은 허리통증 환자의 15-25%를 차지. 

- 최근 연구에 의하면 병력청취, 이학적 검사, 영상의학 사진으로 천장관절 통증을 진단하는 것이 완전치 않음. 

- 확진은 천장관절에 신경차단술을 시행

Anatomy

The sacroiliac (SI) joint is the largest axial joint in the body, with an average surface area of 17.5 cm2 (1). There is wide variability in the adult SI joint, encompassing size, shape, and surface contour. Large disparities may even exist within the same individual(2,3). 

- 천장관절은 인체에서 가장큰 축관절. 평균 면저 17.5cm2

- 성인의 천장관절은 넓은 변이가 있음. 관절이 만나는 크기, 형태, 관절면 등..

- 심지어 한 개인에게서도 양측 천장관절은 큰 차이를 보이는 경우도 있음. 

The SI joint is most often characterized as a large, auricular-shaped, diarthrodial synovial joint. In reality, only the anterior third of the interface between the sacrum and ilium is a true synovial joint; the rest of the junction is comprised of an intricate set of ligamentous connections. Because of an absent or rudimentary posterior capsule, the SI ligamentous structure is more extensive dorsally, functioning as a connecting band between the sacrum and ilia (4). The main function of this ligamentous system is to limit motion in all planes of movement. 

- 천장관절은 크고, 귀모양의 움직이는(diarthrodial) 활액관절(synovial joint)

- 실제로 천골과 장골의 앞쪽 1/3면이 만나 관절을 이루는 부분이 활액관절임. junction의 나머지부분은 인대연결의 복잡한 set로 구성됨. 

- 후방관절낭이 없거나, 미발달하기 때문에, 천장관절의 인대구조는 뒤쪽에 좀더 확장적이고, 천골과 장골사이의 연결밴드로서 기능함. 

- 인대 시스템의 주요기능은 움직임면에서 motion을 제한하는 것임. 

In women the ligaments are weaker, allowing the mobility necessary for parturition (Figs. 1 and 2). The SI joint is also supported by a network of muscles that help to deliver regional muscular forces to the pelvic bones. Some of these muscles, such as the gluteus maximus, piriformis and biceps femoris, are functionally connected to SI joint ligaments, so their actions can affect joint mobility. The potential for vertical shearing is present in approximately 30% of SI joints, owing to the more acute angulation of the short, horizontal articular component (5).

- 여성은 인대가 약해서, 출산을 위해서 필요한 움직임을 허용함. 

- 천장관절은 또한 근육 네트워크로 지지되어 국소적 근육힘이 골반으로 전달되는 것을 도움. 

- 대둔근, 이상근, 대퇴이두근 등은 천장관절 인대를 좀더 기능적으로 연결함. 그래서 근육의 활성은 관절움직임에 영향을 줄 수 있음. 

- 천장관절이 짧고, 수평적 관절구성물의 좀더 정확한 각도덕분에, 수직전단력이 천장관절의 30%를 유지함. 

Age-related changes in the SI joint begin in puberty and continue throughout life. During adolescence, the iliac surface becomes rougher, duller, and coated in some areas with fibrous plaques. These senescent changes accelerate during the third and fourth decades of life and are manifested by surface irregularities, crevice formation, fibrillation and the clumping of chondrocytes. 

- 나이가 들어감에 따라 장골면은 더 거칠고.. 섬유성 plaque가 존재.. 관절면이 불규칙적이고 ....

- 천장관절의 노년변화는 30-40대에 가속화되는데, 천장관절면의 불규칙, 갈라진 틈생성, 미세섬유형성, 연골세포의 변형 등

Degenerative changes on the sacral side generally lag 10–20 yr behind those affecting the iliac surface. In the sixth decade, motion at the joint may become markedly restricted as the capsule becomes increasingly collagenous and fibrous ankylosis occurs. By the eighth decade of life, erosions and plaque formation are inevitable and ubiquitous (4).

- 천장관절면의 천골면 퇴행성 변화는 장골면에 비해 10-20년 늦게 발생함. 

- 60세즈음에 천장관절의 motion은 심하게 제한되고, 섬유성 강직이 일어남. 

- 80세에는 erosion and plaque 형성을 피할 수 없음. 

Innervation

The innervation of the SI joint remains a subject of much debate. The lateral branches of the L4-S3 dorsal rami are cited by some experts as composing the major innervation to the posterior SI joint (1). Other investigators claim

that L3 and S4 contribute to the posterior nerve supply (6,7). The innervation of the anterior joint is similarly ambiguous. 

- 천장관절을 지배하는 신경에 대해서 많은 논란이 있음. 

- L4-S3 후신경가지가 천장관절 후방에 주요 지배신경임. 

- 다른 연구는 L3, 4라고 주장함. 

- 천장관절 전방 신경은 논란이 훨씬 많음. 

Early 20th century German literature asserts the anterior SI joint is supplied by the obturator nerve, superior gluteal nerve and the lumbosacral trunk (8). More recent literature suggests the anterior joint is innervated by L2-S2 (1), L4-S2 (9), and the L5-S2 ventral rami (10). Some authors have even suggested that the anterior SI joint is devoid of nervous tissue (7,11). In a study testing the ability of L5 dorsal ramus and S1-4 lateral branch blocks to protect the SI joint from an experimental stimulus, 6 of 10 subjects retained the ability to perceive ligamentous probing (12).

- SI 관절은 폐쇄신경, 상둔신경, Lumbosacral trunk가 지배.

A neurophysiologic study conducted in cats identified 29 mechanosensitive afferent units, 26 of which were found in the joint capsule and 3 in adjacent muscles (13). Twenty-eight of these units were classified as nociceptive and 1 as proprioceptive. Among these 29 receptive fields, 16 were located in the proximal third of the posterior SI joint and 11 in the middle third. The average mechanical threshold of an SI joint nociceptive unit was 70 g, as compared to the 6 g mean mechanical threshold for lumbar facet joint nociceptive units and the 241 g threshold for units residing in the anterior lumbar disk (14 –16). This indicates that the pain sensitivity of the SI joints may be lower than that of the lumbar facet joints but higher than the anterior portions of lumbar discs. As all animals underwent posterior midline incisions, somatosensory units in the anterior SI joint were not stimulated.

- 형태학적인 검사결과(쥐 연구) 29  mechanosensitive afferent unit, 그중 26개가 관절낭에서 발견, 3개는 주위근육에서 발견됨. 

- 28개의 신경 다발은27개는 nociceptive이고1, 1개는 proprioceptive임. 

Function and Biomechanics

The SI joints are designed primarily for stability. Their functions include the transmission and dissipation of

truncal loads to the lower extremities, limiting x-axis rotation, and facilitating parturition. Compared to the lumbar spine, the SI joints can withstand a medially directed force 6 times greater but only half the torsion and 1/20th of the axial compression load (17). These last 2 motions may preferentially strain and injure the weaker anterior joint capsule (18).

-  천장관절은 안정성을 위해 디자인됨. 

- 천장관절의 기능은 몸통부하를 하지로 전달, 분산하는 것, 교차축회전 제한, 출산을 촉진하는 것 등을 포함함.

- 요추와 비교하여 천장관절은 내측으로 6배힘을 더 견딜 수 있지만 torsion은 1/2, 축성압박부하는 1/20힘을 견딜 수있음. 

There have been numerous attempts to discern the biomechanics of the SI joint. These motion studies can be summarized as follows: the SI joint rotates about all 3 axes, although the movements are very small and difficult to measure (19,20). Miller et al. (21) studied the load-displacement behavior of single and paired SI joints in 8 elderly cadavers. Various static test loads were applied in the superior, lateral, anterior and posterior directions, and rotations about all 3 axes were measured. These tests were conducted with one and both ilia fixed. The authors found that with 1 leg immobile, movements in all planes ranged from between 2 to 7.8 times more than that measured with both legs fixed. 

- 천장관절의 생체역학적 연구는 많이 진행됨. 

- 천장관절은 3 축에 대하여 회전, 움직임은 매우 작고 측정하기 힘듬. 

- 다양한 적정 검사부하가 위, 옆, 전, 후방향, 회전방향으로 모든 3축으로 진행됨. 

- 이 검사는 양측 장골고정, 한쪽장골 고정으로 진행함. 저자는 한다리 고정한 움직임에서 양측다리를 고정하고 측정한 것보다 2-7.8배 더 많이 움직임. 

In a series of cadaveric studies, Vleeming et al. (22,23) found that the total range of motion during flexion and extension at the SI joint rarely exceeded 2 degrees, with 4 degrees being the upper limit during sagittal rotation. In another cadaver study, Brunner et al. (24) found that the main motion in male specimens tended to be translation, whereas in female specimens it was rotational. 

- 천장관절의 굴곡과 신전 겨우 2도. 시상면 회전동안 4도에서 제한됨. 

- 다른 연구에서 남성은 translation이 우세한 반면, 여성은 회전이 우세함. 

The maximum range of motion in this study was 1.2 degrees in men and 2.8 degrees in women. In a study by Egund et al. (25) examining SI joint movements in 4 volunteers using radiographic stereophotogrammetry, the authors found the maximal rotations and translations to be 2.0 degrees and 2.0 mm, respectively.

- 천장관절의 최대 rom은 남성에서 1.2도, 여성에서 2.8도

- 연구에 의하면 최대 회전과 translation은 각각 2도, 2mm 임. 

A larger study (n
24) by Jacob and Kissling (26) conducted in healthy young and middle-aged men and women found similarly small limits on rotation (1.7 degrees) and translation (0.7 mm). However, one individual with a history of SI joint pain exhibited more than 6 degrees of rotation about the y-axis. Finally, Sturesson et al. (27) measured multiple SI joint movements in 25 patients diagnosed with SI joint pain. Movements in all planes were found to be small, with translations never exceeding 1.6 mm, and rotations being limited to 3 degrees.

- 천장관절 움직임에 대한 논란...

No differences were found between symptomatic and asymptomatic joints, leading the authors to conclude that 3-dimensional motion analysis was not useful for identifying painful SI joints in most patients. Possible exceptions to the finding that hypermobility is not a typical cause of SI joint pain include traumatic instability, multiparity, muscular atrophy, and lower motor neuron disease (28).

- 통증이 있는 천장관절과 없는 천장관절의 차이는 없음. 

Preval‎ence

Although it is widely acknowledged that dysfunctional SI joints may cause low back pain (LBP), the preval‎ence of this condition has not been well studied. Preval‎ence studies are further compromised by the fact that most have used either physical examination findings and/or radiological imaging techniques to make the diagnosis of SI joint pain. The largest of these is a retrospective study by Bernard and Kirkaldy-Willis (29), who found a 22.5% preval‎ence rate in 1293 adult patients presenting with LBP. Diagnoses in this series were based predominantly on physical examination.

- 천장관절 기능부전은 하부요통의 원인으로 알려져있으나.. 그에 관한 연구는 미진한 편

- 연구에 의하면 하부요통환자의 22.5%환자에서 천장관절의 기능부전이 있다고 함. 

Schwarzer et al. (30) conducted a preval‎ence study involving 43 consecutive patients with chronic LBP principally below L5-S1 using fluoroscopically guided SI joint injections. Fifty-seven other patients with LBP were excluded on the basis of more rostral symptoms. 

Three criteria were used to diagnose SI joint pain: analgesic response to local anesthetic (LA), abnormalities on post-arthrography computed tomography (CT) scanning, and concordant pain provocation during joint distension. Using significant pain relief after LA injection as the sole criterion for diagnosis, the preval‎ence of SI joint pain in the 43 subjects was determined to be 30% (95% confidence interval [CI], 16%–44%), with 4 patients obtaining complete pain relief. Using analgesic response combined with a ventral capsular tear (the most common radiologic finding) as the criteria, the preval‎ence decreased to 21% (95% CI, 9%–33%). Only 7 patients satisfied all 3 diagnostic criteria, for a lower limit preval‎ence rate of 16% (95% CI, 5%–27%). The presence of groin pain was the only referral pattern found to distinguish patients with SI joint pain from those with LBP of non-SI joint origin.

- 천장관절 통증환자의 세가지 진단

# 국소마취제 local anesthetic

# CT

# 이학적 검사

Maigne et al. (31) conducted a preval‎ence study in 54 patients with unilateral LBP using a series of blocks done with different LA based on International Spinal Injection Society guidelines (32). Nineteen patients had a positive response (
75% pain relief) to the lidocaine screening block. Among these patients, 10 (18.5%) responded with 2 h pain relief after the confirm‎atory block with bupivacaine and were considered to have true SI joint pain (95% CI, 9%–29%). Based on these studies, the preval‎ence of SI joint pain in carefully screened LBP patients appears to be in the 15%–25% range.

- 이렇게 세밀한 연구에 기초하여 천장관절 통증환자를 살펴보니 하부요통환자의 15~25%에서 천장관절통증...

천장관절 손상 메카니즘.

Mechanism of Injury

The mechanism of SI joint injury has previously been described as a combination of axial loading and abrupt rotation(18). On an anatomic level, pathologic changes affecting many different SI joint structures can lead to nociception. These include capsular or synovial disruption, capsular and ligamentous tension, hypomobility or hypermobility, extraneous compression or shearing forces, abnormal joint mechanics, microfractures or macrofractures, chondromalacia, soft tissue injury, and inflammation.

- 천장관절 손상의 기전은 축성부하와 갑작스러운 회전

- 관절낭 손상, 관절낭과 인대의 장력, 저운동성 또는 과운동성, 외부 압박 또는 전단력, 비정상적인 관절부하, 미세파열 또는 대골절, 연골연화증, 연부조직 손상, 염증 등이 원인

Mechanistically, there are numerous reported etiologies for SI joint pain. To simplify matters, these causes can be divided into intraarticular and extra-articular sources. Arthritis and infection are two examples of intraarticular causes of SI joint pain. Extra-articular sources are the more common of the two and include enthesopathy, fractures, ligamentous injury, and myofascial pain. Clinical studies have demonstrated significant pain relief after both intraarticular and periarticular SI joint injections (33–36).

- 천장관절 통증을 두가지로 구분하면 "Intra-articular and extra-articular 요인"으로 나뉨

- 관절염과 감염은 천장관절내 통증의 원인임

- 천장관절외 통증 원인은 골-근부착부질병(enthesopaty), 골절, 인대손상, 근막통증

In addition to etiologic sources, there are numerous factors that can predispose a person to gradually develop SI joint pain. Risk factors that operate by increasing the stress borne by the SI joints include true and apparent leg length discrepancy (37), gait abnormalities (38), prolonged vigorous exercise (39), scoliosis (40), and spinal fusion to the sacrum (41). 

- 점차적으로 천장관절통증을 야기하는 질환은 많음

# 다리길이차이

# 보행장애

# 과도한 운동

# 측만증

# 천골과 요추의 fusion

Whereas increased SI joint uptake using scintigraphy has been demonstrated after lumbar spine fusion (42), at least one study examining the long-term effects of spinal fusion on SI joint function concluded that neither  biomechanical nor anatomical changes were more common in fusion patients than in those who underwent decompression procedures (43). 

- 요추 5번과 천골을 유합하는 수술이 많아짐. 

- 요추 5번과 천골 수술을 하면 생체역학적, 해부학적 변화가 흔하게 나타남. 

Lumbar spine surgery has also been purported to trigger SI joint pain for reasons unrelated to increased force transmission. These factors include SI ligament weakening and/or surgical violation of the joint cavity during iliac graft bone harvest (44) and postsurgical hypermobility (45). 

- 허리 수술은 천장관절 통증을 유발하는 주요 요인

- 천장관절 인대 약화, 수술후 관절가동성 증가 등

Pregnancy predisposes women to SI joint pain via the combination of increased weight gain, exaggerated lordotic posture, the mechanical trauma of parturition, and hormone-induced ligamental laxity (46,47). The laxity associated with pregnancy is attributable to increased levels of estrogen and relaxin, and it predisposes parturients to sprains of the SI joint ligaments. SI subluxation has also been reported to cause back pain in pregnancy (48). 

- 임신은 여성 천장관절 통증의 주요 요인, 체중증가, 요추전만증가, 출산시 기계적 손상, 호르몬으로 유도된 인대 약화. 

- 인대약화는 에스트로겐과 릴랙신 분비가 증가하여 인대를 약화시킴. 천장관절 아탈구는 임신동안 요통을 유발하는 요인으로 보고됨. 

Inflammation of one or both SI joints is considered to be an early and prominent symptom in all seronegative and HLA-B27-associated spondylarthropathies (49). Although the precise etiology of spondylarthropathy remains unknown in most patients, the strong association with HLA-B27 supports the view that these conditions are attributable to a genetically determined immune response to environmental factors in susceptible individuals. In a subset of patients with Reiter’s syndrome/reactive arthritis, the disease is clearly induced by infection (50) (Table 1).

- 한쪽 또는 양측 천장관절의 염증은 HLA-B27혈청반응 관절염과 연관됨. 

The specific etiologies that can result in SI joint pain are widespread and protean. Potential causes range from rare events such as pyogenic infection (51) and malignancy (52), to more mundane occurrences such as bracing one’s legs in a motor vehicle accident (53), falls (53), athletic injuries (54), prolonged lifting and bending (55), and torsional strain (55). 

- 천장관절 통증의 원인은 많음

# 화농성 감염(Pyogenic infection)

# 악성종양(malignancy)

# 교통사고, 추락, 운동손상

# 반복된 들기, 구부리기

# 비틀림 손상(torsional strain)

In a retrospective study by Chou et al. (56) assessing the inciting events in 54 patients with injection-confirmed SI joint pain, the authors found trauma was the cause in 44% of patients, 35% were idiopathic, and 21% were attributed to the cumulative effects of repeated stress. In the 24 patients who cited trauma as the source of their pain, the most common events were motor vehicle accidents (n
13), falls onto the buttock (n
6), and childbirth (n
3).

- 후향적 연구에 의하면 44%는 외상, 35%는 원인없음. 21%는 반복된 스트레스의 축적

- 외상중에서 가장 흔한 경우는 교통사고, 엉덩방아, 출산

Diagnosis and Presentation

History and Physical Examination

One of the most challenging aspects of treating SI joint pain is the complexity of diagnosis. Literally dozens of physical examination tests have been advocated as diagnostic aids in patients with presumed SI joint pain (57). Many involve distraction of the SI joints, with 2 of the most common ones being Patrick’s test and Gaenslen’s test. 

- 천장관절 통증 치료는 제일 먼저 진단의 복잡성을 극복해야 함. 

- 가장 흔한 두가지 검사법 "패트릭 검사와 가슬렌 검사"

Despite the plethora of diagnostic tests, clinical studies have for the most part demonstrated that neither medical history nor physical examination findings are consistently capable of identifying dysfunctional SI joints as pain generators (30, 58, 59) (Table 2). In addition, Dreyfuss et al. (60) found 20% of asymptomatic adults had positive findings on 3 commonly performed SI joint provocation tests.

- 많은 천장관절 검사법에도 불구하고, 연구에 의하면 의학적 병력청취와 이학적 검사로 통증원인으로서 천장관절 기능부전을 확인하게 힘듬. 

- 드레이퍼스에 의하면 아무런 증상이 없는 성인 20%에서 패트릭 검사, 가슬렌 검사 등에서 양성임. 

The reliability of provocative SI joint maneuvers and alignment/mobility tests has also been questioned, with most studies conducted by chiropractors and physical therapists. Whereas some of these studies have found moderate to high inter-examiner reliability (61–63), most have not (64–68). 

- 천장관절 검사와 정열, 움직임 테스트의 신뢰도에 의심이 많음. 

Generally, reproducibility has been found to be greater for provocative tests than for mobility and alignment assessments. In the Dreyfuss et al. study (59) conducted in 85 patients with injection-confirmed SI joint pain, there was moderate agreement (kappa
0.6) between chiropractors and medical doctors with regard to provocative maneuvers of painful joints. Even when agreement was perfect, the maneuvers were still found to lack diagnostic utility.

- 일반적으로 천장관절의 운동성과 정열 검사보다는 통증검사에 좀더 재현성이 높음. 

Radiological Studies

Results of studies examining radiologic findings in patients with SI joint pain have been similarly disappointing. In studies by Maigne et al. (69) and Slipman et al. (70), the investigators found sensitivities of 46% and 13%, respectively, for the use of radionuclide bone scanning in the identification of SI joint pain. Despite the high specificites in these studies (89.5% for Maigne et al. and 100% for Slipman et al.), the low sensitivies indicate bone scanning is a poor screening test for SI joint pain. Poor correlation with diagnostic injections and symptoms have also been found for CT and radiographic stereophotogrammetry (71,27). In a retrospective analysis by Elgafy et al. (71), CT imaging was found to be 57.5% sensitive and 69% specific in diagnosing SI joint pain.

Pain Referral Patterns

There have been several attempts to identify pain referral patterns from SI joints. In one of the earliest studies conducted in 10 asymptomatic volunteers, Fortin et al. (72) performed provocative SI joint injections using contrast and lidocaine. Sensory changes were localized to the ipsilateral medial buttock inferior to the posterior superior iliac spine in 6 of the 10 subjects. In 2 subjects, the area of hyperesthesia extended to the superior aspect of the greater trochanter. The last 2 subjects experienced sensory changes radiating into the upper thigh. In a follow-up study, independent examiners selected 16 individuals among 54 with chronic LBP whose pain diagrams most closely resembled the pain referral patterns obtained in the first study (73). These 16 patients proceeded to undergo provocative SI joint injections with contrast and LA. All 16 experienced concordant pain during the injection, with 14 obtaining pain relief after deposition of LA. 

Ten patients reported
50% pain reduction. Six of the 16 patients had ventral capsular tears revealed during arthrography. After the SI joint injections, provocative discography and lumbar facet joint injections were performed in 9 patients each. In none of the patients was either test positive.

Slipman et al. (74) conducted a retrospective study to determine the pain referral patterns in 50 patients with injection-confirmed SI joint pain. In contrast to the findings by Fortin et al. (72) and Schwarzer et al. (30), the authors found the most common referral patterns for SI joint pain to be radiation into the buttock (94%), lower lumbar region (72%), lower extremity

(50%), groin area (14%), upper lumbar region (6%), and abdomen (2%). Twenty-eight percent of patients experienced pain radiating below their knee, with 12% reporting foot pain. Based on the existing data, the most consistent factor for identifying patients with SI joint pain is unilateral pain (unless both joints are affected) localized predominantly below the L5 spinous process (30,59,72–74).

다른 논문 그림

1985년 REVIEW 논문

Function and Pathomechanics of the Sacroiliac Joint.pdf