Within the therapy world the assessment and treatment of the Sacroiliac Joint, or the ‘SIJ’ as its more commonly known, is a fiercely debated area that creates lively arguments and disagreements between therapists, as I recently found out when I posted a comment on Twitter a while ago stating I was surprised that many still use palpation tests to assess it. After some much RSI inducing tweeting, which ended up with one tweeter calling me a ‘critical arse’ forcing me to write another post here. I thought I would write this piece on what my clinical experience and more importantly what the research is telling us on how we should be assessing the Sacroiliac Joint.
Now for me the SIJ has always been one of those areas I never did like or fully understand when I was a fresh faced student many years ago. I can recall being in physio classes being confused as hell listening to the arthrokinematics of the joint during movment, and how alterations to these joint movements can cause pain and dysfunction. Then in practical sessions I would be even further confused as a tutor would tell me to press one of my class mates lower back and pelvis and say…
“can you feel that counter nutation of the sacrum”
“do you feel that blocked left sided innominate”
“Err…. yeah sure….” i’d reply sheepishly im sure with a confused and bemused look on my face!
But if I’m being honest, all I felt during these practicals and still do now when I assess the pelvis was skin and some bony bits, and not much moving anywhere at any time. However, everyone else in my class seemed to be able to feel stuff, so I kept quiet and kept and prodding and poking to see if I could develop the feel, daring not question the absurdity of trying to feel these small, subtle movements through thick dense tissues.
I thought I’m just new at this, I just needed to develop my palpation skills, especially as so many other physios kept telling me that they could feel the SIJ moving or not. So I perservered on and every opportunity I got, I pressed, poked, and prodded peoples SIJs, I just wanted to get better at feeling the movements and doing the tests…
But I didn’t get any better! I still couldn’t feel anything!
So I thought I needed some more teaching, so I went on a very well known SIJ post graduate course with a very well known international pelvic specialist hoping this would make me an SIJ assessing machine…
It didn’t.
Instead, I now had to deal with identifying a further 6 planes of movement including rotational and twisting movements, out flares, and other weird sounding stuff that I was supposed to be able to detect.
I spent two days with this expert pretending I was a sacrum with my arms up out to the side twisting this way and that, as well as pressing a lot of backsides (some nicer than others mind) and again having to listen to my class mates shouts of joy when they felt an anteriorly rotated innominate, or gasps of amazement when an upslip was found, it was like being back at Uni all over again… Again all I could feel was skin and some bony stuff not moving anywhere significantly, but I now also had a despondent feeling… What was going on? Why couldn’t I just feel this stuff?
Was I just a ham fisted numpty that couldn’t feel anything?
Well actually no I am not as it turns out. There is actually heaps of good evidence that palpation tests of the SIJ are extremley unreliable and show poor inter-tester reliability.
Holmgren and Waling showed that four common static tests used to detect asymmetry is of “doubtful utility“, and a study by McGrath questions the ability to detect the commonly used bony landmarks stating “the continued use of manual diagnostic palpation as a basis for manipulative intervention is questionable“. And a study by Preece et al highlights the vast anatomical differences that there are in the human pelvis and that variations in pelvic morphology “may significantly influence measures of pelvic tilt and innominate asymmetry“
So these papers, and others, show that feeling for SIJs movement if not releiable and not going to give any useful information about the SIJ position.
But what about those claiming they can feel the SIJ move or not move?
Well, we know that although the SIJ is a joint and it does moves, it doesnt move much. In fact it moves just a few degrees, totalling just a few millimeters of actual movement. Goode et al shows at maximum its about 8mm of movement, realistically its less than this with average movements being quoted as around 2-3mm.
Three good papers look at the commonly used movement assessment tests used in ‘feeling’ for SIJ movement, these are the Stork and Gillet’s tests, two from Freburger and Riddle here and here both showing poor inter tester reliability, low sensitivity and poor specificity, and another by Robinson et al confirming the other two studies, basically telling us that we just can NOT reliably feel the SIJ move or not.
So combine poor palpation reliability with very small movements underneath lots of layers of connective tissue and I hope you can begin to realise and understand that feeling for a SIJ’s movement with touch is implausible and delusional. However, the techniques are still very popular and many claim they can detect these movements despite the evidence saying otherwise. Why?
Personally I think this is just therapists desperately trying to hang onto something they have invested a lot of time and training into, as well as gurus and their disciples defending the beleif to prevent them looking or feeling silly. I also think it give therapists a sensation of control over a very uncertain area, even in the face of over whelming evidence and common sense.
So where does this leave us therapists (and the patients who may also be reading this as well) when we do suspect the SIJ maybe a source of pain (which is very rare in my opinion, but that’s for another post) how do we reliably assess it?
Well there are tests we can do, in fact its more a group of tests and it doesn’t involve trying to palpate microscopic movements here and there. These tests in combination have been found to be so much more reliable and sensitive in determining IF an SIJ is causing pain rather than trying to determine if its moving too much or too little, or its twisted this way or that, which doesn’t really matter if its not causing any pain.
First is using the location of pain, Van der Wurf et al showed that you can possibly predict an SIJ issue if the pain is located in whats called the ‘Fortin’ area but NOT in the ‘Tuber’ area see below image
However you can’t just use the location of the pain alone, we need other tests to confirm the SIJ is an issue. Laslett et al seminal paper along with another by Van der Wurf et al shows that there isn’t one stand alone test but rather a combination of 5 tests and if 3 or more are positive then there is a 79% specificity for saying the SIJ is the issue.
These tests are
- Gaenslen torque test
- FABER’s (Patricks Test)
- Femoral shear test
- ASIS distraction test
- Sacral thrust test
Video demonstrations of these tests can be seen on this Youtube site.
I would also add to this list the Active Straight Leg Raise or ASLR test as it has also been found to be validated to highlight pain from the posterior pelvic area here
So in summary I hope you can see that trying to assess a SIJ by its position and movement or lack there of, using palpation tests you are barking up the wrong tree and will not gain any useful or relevant information. In fact it can lead you down the wrong road of treatment completely. Just because a SIJ is slightly this way or that compared to a so called ‘normal’ SIJ (whatever that is) doesn’t mean its a source of dysfunction or pain, and that goes for any joint/posture!
I would ask that if you are a therapist that still uses palpation test to assess the SIJ to strongly question your reasons for doing this and look at what the evidence is telling us, and STOP. If you are a patient with a suspected SIJ issue and you have a therapist palpate your SIJ claiming they can feel it move or not I would question them why they are doing it or just walk away.
I’m sure this will create some mixed feelings as it did last time I mentioned it, please feel free to comment and discuss the issues I have raised but remember be polite, curtious and respectful, after all I have reflected and feel that actually im not a critical arse… most of the time
Once again thanks for reading
Happy exercising
Adam
Hey again Adam!
Great job reviewing the literature on the subject, and congrats on being so honest with your “learning process” on the SIJ assessment. It seems, by the books or by some people behaviour, that SIJ assessment is something simple and easy, and everybody can do it. Regarding that, I share the same feelings as you, as it is not easy for me to sense SIJ position or movement. The feeling that I have when reading books on the subject is that, somehow, I have no talent or skill in SIJ assessment and everyone else does. Somehow similar to yours.
I believe that the thing that mostly motivates me to keep assessing the SIJ is the fact that “it seems I am not good enought yet to sense it, so I need to keep practicing!”. And, in a semi-scientific way, trying to find something that is really accurate, or learning more. It takes some time from the treatment session and that is not good. But at the same time it brought me a few experiences over the years.
I should mention that I, other than palpation of the bony landmarks, I had not SIJ movement or special tests assessment on university. Everything came after, mostly by books, few things by courses I had taken.
My experiences concern tests that were not mentioned, like the Gillet, sitting flexion and standing flexion tests. Specially the two first ones.
What I have to say is that most tests I do are inconclusive, in some nothing is found, and in others there is assymetry of movement or fixation. I know that evidence show that, even then, anatomical differences between the sides could be the reason. I would add that some people don’t execute the movement correctly (Gillet test specially, ts like their movement strategy of raising one leg is… for a lack of better word… wrong , or not suitable to the test). However, there were occasions where I noticed the lack of movement and tried to be specific about the correction of the movement, and what I got was reduction of pain and raised confort. Not always, not with everyone.
However, what you brought in this article about assessing SIJ through the location of pain is what, without having had access to those articles before reading from you, I had been doing and what had been most accurate (not trying to imply that I am a guru or something, just that the pain usually is located at or very near to the site of pain) to me. It seems to me more accurate even than the cluster of tests, but this is just an opinion.
So, these are my thoughts and a few experiences with SIJ assessment. I would like to add that, IMHO, large fixations are not as usual today as they could have been in the past, so its harder to notice them through the tests. In the “ancient times” it would be easier to find these on the general population, and the manual tests of palpation could have been more reliable then.
Congrats on the article!
Cheers,
Claudio
Hey Claudio
Many thanks for your comments, I do like your passion for these things, matches my own!!!
I hear what you are saying and believe me I tried for years and years and felt 100s if not 1000s of SIJ still no change in what I could feel
We just can’t ignore the evidence telling us we can’t reliably feel the SIJ move or other wise
Maybe we can get an idea if its a hyper or hypo mobile perhaps but even that is debatable
Again thanks for your comments
Cheers
Adam
Ham fisted numpty is going to be my new insult, for sure.
I did have a PT diagnose me with SI joint uh….messed upedness, don’t remember the actual term, and treatment made a big difference in pain and function. I think he did the tests, and palpation both.
Nice post here. I have memories of trying to diagnose SIJ dysfunction as well. I don’t discount that manual therapy treatments directed towards treating supposed SIJ dysfunction can help patients feel better. Perhaps you give them a story that they can buy into and provide mechanical input into their nervous system and this is what accounts for improvement. However what does this do to the patient’s belief system? Do they attribute their pain now to an altered SIJ alignment? What are the long term consequences of this? This is similar to patients being told that their SIJ is unstable and requires enhanced stability.
Those notions aside as you mentioned the evidence supports the SIJ pain provocation tests. If you have a positive cluster what intervention is then indicated? These tests don’t provide a direction for management, they only indicate the SIJ as a potential source of symptoms. Thoughts?
Hi Bill
Thanks for your comments, yes your right to think this, the tests tell us that the SIJ is the source of pain not how to best manage or treat it.
I will be doing a follow up post on that subject soon as its been requested by others
Cheers
Adam
So the tests don’t mean anything to you? What does it look like when they walk? Does gravity pass through the joint, or do they need to move around it? Perhaps ’cause and effect’ relationships and how they are described and tested are leaving you a little dry, but don’t give up just yet. Life isn’t a multiple choice test.
All the best 🙂
Hi Ben
Thanks for the comments, I think?
I won’t give up dont you worry about that pal I’ve got too many deluded therapists to re-educate
Of course these aren’t the only 5 tests to do, of course you gain info and clues from the subjective and objective assessment, of course you move them around and observe them moving first before the ‘special’ diagnostic tests are used to confirm your diagnosis
Your missing the point of the post, STOP feeling the SIJ and saying you can feel it move or not, your suffering from Palpatory Pareidolia!!!
Please if you still are doing this then please give up, life isn’t about feeling things you just can’t feel
All the best back at ya
🙂
Great post Adam. Very helpful for students like myself who struggle with this area. It would be very interesting to hear your opinion on where to go should you identify true SI joint pain.
Thanks Greg
I will be doing a follow up piece just on that topic soon as it seems a popular request with a few other readers, so watch this space
Thanks for your comments
Cheers
Adam
Thank you! I am a massage therapist, so not in the game of diagnosis, but it has always bothered me to hear of SIJ diagnosis through palpation as I could never feel what I am supposed to, and as that is ALL I do, I know my palpation skills are better than most physio therapists. So in future I will be more crirical of a diagnosis.
Hi Adam, having been in the massage and Bowen Therapy world in Australia for over 25yrs I find your post simply wonderful! Its a breath of fresh air to “hear” you talk. Although I don’t diagnose I do need to assess, so I will be back to check out your other posts. I am sure I will learn a lot.
Thanks again
Brigid
Hi Brigid
Thanks for your very nice comments, more to follow shortly on this and other areas
Regards
Adam
I’m one of the old school deluded manual therapists who uses palpation, mobility tests and the pain provocation tests you discuss. I find all to be helpful and generally find my clients achieve good results.
As readers have said if you use pain provocation tests you are more certain the SI is the source of symptoms, but I would be curious to know if you don’t assess SI mobility and you don’t do manual therapy, how do you treat these people and how do you know whether they need exercises to stabilize, mobilize etc?
Do you totally discard the notion that there can be a movement dysfunction in the SI joint itself? Marj
Hi Marj
Thanks for your comments, of course I don’t discount that the SIJ is a joint and that it can move, its just that it moves so little that I, as the research does, question that anyone can feel this reliably and determine anything from these palpation tests.
Basically its not about using the provocation tests in isolation and im not advocating this, but rather I’m saying use them with other visual and verbal clues from the assessment to inform and guide your decision making process to help you decide if the SIJ is the problem and how best to treat it, but the notion of palpating the SIJ for movement is frankly a waste of time and of no use
I am going to be doing a follow up piece on how best according to the evidence and my experience again to treat an SIJ once you have found it to e a source of pain
Regards
Adam
Nice post Adam,
from a clinical reasoning standpoint, one would also be a little more suspicious of a possible SI involvement in a hypermobile 25 yo female, or 2 month postpartum female with reports of buttock pain as opposed to a 50yo male with buttock pain, which would lead to you doing the tests described by laslett. et al.
Clare
Hi Clare
Yes your absolutely right the subjective clues would also guide your diagnosis, the physical assessment tests are just part of the story
Thanks for your comments
Adam
Adam,
It is great that you are “coming out” questioning all the tests for an area that is squirrelly at best to assess. I use some of the provocative tests but mostly positional assessment for comparison pre and post treatment and in relation to the rest of the body.
Regardless of your assessment, I believe the SI area often has more to do with the dynamic forces passing through than true local SI disfunction. Even with a hypermobile SI, I believe the functional relationship of the pelvis to other areas of the body is more important. This is why stabilization exercises work well, though not as well when there is a structural mal-alignment over all.
Since you have been researching the literature, what assessment techniques have you found that address the whole body? I use Aston-Kinetics Assessment techniques to look at specific alignment, function and tension patterns with great success. Just wondering what you have found?
Hi Michelle
Thanks for your comments
I have come across many methods for assessing movement, from the FMS to your mentioned Aston techs
Unfortunately I’m not a fan of these methods, I find they try and fit people into boxes and I find movement is so unique to the individual, and to the task the frequency and amount that these methods don’t hold much use for me.
Instead I am more interested in if the movement is firstly painful, secondly efficient and then work and address these
Regards
Adam
Adam
I guess you don’t know much about the Aston Kinetics techniques which is not only assessment, bodywork, specific movement coaching, fitness and ergonomics, because it is totally individualized and specific to the individual.
The Aston Kinetics system is utilized by professional athletes and the average person alike to solve their painful issues that have not been resolved by other techniques. This makes it more challenging to explain because there are no Boxes in Aston Kinetics, so you may want to investigate it further before making assumptions.
Want to know more? http://www.MichelleWald.com
http://www.AstonKinetics.com
Thanks for your comments again Michelle
I’m sorry but your are taking my comments as assumptions when they are opinions
What I was trying to get across is that I find no one method is better over another in my experience, having read countless books, papers etc and tried loads of various methods of screening, assessing and measuring human movement I find having a wide and varied exposure to many different methods but ultimately using your own judgement, skill and experience is best… I call this the “Meakins Method/Techniques/Approach” and although no fancy books, websites or courses I find it works well for me but probably no one else!
I’m not a fan of following other “guru’s” methods rather designing my own
Kindest regards
Adam
Agreed; i hate the ‘approach’ method. I working in China atm, and their local physio’s and dr’s alike keep asking, ‘oh so what method is that? is that FMS, or is that such and such..??” “i’m like no, it’s a single leg squat with my observation”, and it’s part of my clinical reasoning process….they are like oh so it’s a xxx method, umm no i didn’t know they could trademark a single leg squat, but ok whatever…. Yes i agree. I think those ‘approaches’ just limit the clinical reasoning process, why follow systems? Ive seen cases where they had knee pain for example, and done the same exercise for 2 years, because the China physio used a system/approach, that put them in a box, and in that method thats the “corrective exercise” they do for that. Hmmm….but they didn’t think to change that reasoning after 2 years? Oh no, answer they gave me was “maybe this patient is just no good.”……Stick to the science, and not becoming a FMS, AST, ART, AMR ect..certified clinicans.
Hello there Adam.
Your SIJ post made me start to research again. Not with scientific papers, but applying and thinking about these tests (Gillet, extension Gillet, sitting flexion, standing flexion) and double check if they do actually work work or we are gtting into palpatory pareidolia.
However, my approach now is different than before. Previously it was these tests do work, I cant do them, let me practice and let me try to find things!”. Now the approach is “these tests do not work, let me see why they seem to work!”
I started today, picking every person in my house on the free time and doing those tests with the new approach. Nobody has any pain problems. I also tried those on myself (awkward to think about, I just put my hands on my PSIS -suposedly so- and same sacral level).
Well, let me talk about the flexion Gillet test first. Suposedly it is an osteokinematic movement of the hemipelvis on the sacrum (like a shoulder flexion is an osteokinematic movement; its different from a umeral glide on the glenoid fossa, this would be an arthrokinematic). Its hard to do the correct movement as people tend to rotate the weightbearing hip, twisting all the pelvis towards you (which may give the impression of the PSIS coming posteriorly – one of the itens I was taught to look for, as it is meant to be a signal of the expected correct movement of the pelvis), or people bend the weight bearing knee and retrovert the pelvis. These are two common mistakes. When these are avoided or corrected you have what can be called the correct movement. What I have found is that on flexing the knee you will have a greater activity of the paravertebrals which get thicker due to their contraction, and this can make people think that the PSIS changed its position. It can also make people think that the sacrum is now deeper (anterior) than the PSIS, which is more posterior (anterior sacrum, posterior PSIS, correct movement, suposedly). Besides that, the PSIS can really move down, but it takes the sacrum with it, however, the tissue stretch that happens on the side buttock pulls your palpating finger more than the finger on the sacrum. This gives the impression that the PSIS wentdown in relation to the sacrum, and that this is the correct movement.
Okay, now to the Gillet test for extension. In this you basic do a hip extension (knee extended) and check for differences between the PSIS and the sacrum. Similarly to the “regular” Gillet, in this one the movement of hip extension contracts the glutes, which get thick and give the impression that either the palpating finger went deep, or push the palpating finger superiorly.
The problem is, I managed to indetify people that had SIJ pain with positive Gillet tests. What could have happened? What might I (or anyone who happened to do the same) have corrected? Either the muscle activity got better, giving the impression I had when doing the correct movement, or the muscle tissue that was shortened and might have been released with the HVLA now allowed the PSIS to move down, and making me having the impression that the PSIS went lower than the sacrum (which it actually didnt as explained above). The pain could have been being caused by shorteded muscles that would not allow or would make it more difficult to posteriorly tilt the pelvis, the paravertebrals, maybe fibers of the gluteus, could be it (gotta recheck that). It was released, now the pelvis with the sacrum are free to move as a unit, as they usually are (assuming that there is no palpable movement).
Tricky, hen?
Now, lets go to the sitting and standing flexion tests. In these you try to compare both PSISs movement when the patient bends forward. I will share my experience to try to explain what happens. Well, it can happen in both tests, but to me it happened in the sitting version. Person bends forward, right site goes upper than left. Patient was complaining of pain on the buttocks. I pushed the PSIS down and asked the movement (mobilization with movement) a few times, and again. On retest, PSISs were level and patient had no more pain. Assuming there is no SIJ movement (palpable at least) two possible things. Slight trunk rotation (or one pelvis sitting a little in front), which could give the impression the same side PSIS went up when patient is forward bent or tissue shortening (muscle, etc). By pushing the PSIS either the patient can correct his rotation, or you stretch/release the muscle or tissue.
Not sure if I made my explanations clear. Might have to work on that again.
These are my first impressions with the new context of viewing things.
Believe it can add a little bit.
We’ll keep going on with this semi-scientific research.
Cheers,
Claudio
I found your post interesting but I would like to say that with those tests you can identify if the si joint is the origin of the pain and treat it. The problem is when the si joint is not the origin of the pain but it has to be treated for resolving regional problems such us L5-S1 dysfuntions or hip and groin problems. I such a case mobility and fault position has to be assesed manualy and with ather tests that are not based in pain provocation
Hi Thomas
Thanks for your comments
That was the reason for the post as I find clinically the SIJ is NOT the source of pain as much as people or therapists think or claim, a lot of people have been told or think they have a SIJ problem when u correctly say its normally and more likely to be the Lumbar spine
Cheers
Adam
Great point here. Given the much higher prevalence of the lumbar spine as the source of pain perhaps we should only rule in the SIJ after we have ruled out the lumbar spine (and possibly the hip as well)?
Laslett recommends a MDT evaluation of the lumbar spine first; if you identify a directional preference or centralization then you don’t need to test the SIJ. See the article linked below. This is a good free review article; it might be biased towards MDT but overall seems rational and germane to this discussion.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582421/
One final thought. Someone could potentially have Both the lumbar spine and SIJ as sources but that is less likely unless we are talking about pregnancy related back pain.
Bill
Hi Bill
Thanks for your comment
Yes I definitely think its paramount that the lumbar spine is looked at first as most of the time the SIJ probably won’t need to be ‘fully, assessed (if that’s even possible, I’m in the process of writing another article on just that as we speak) but rather quickly cleared as a source of pain with the pain provocation tests I mention here
This review http://www.ncbi.nlm.nih.gov/pubmed/23253394 shows that the prevalence of the SIJ as a source of mechanical pain is between 10-30% relatively low in the scheme of things but still worth clearing just as you say in case there is both, but again the subjective clues will more than likely guide here as well
Thanks for joining in the debate
Regards
Adam
Hi there,
In order to move this discussion forward may I point you in the direction of the work by Diane lee and LJ Lee and their ISM model.
Regards,
Tobias
Hi Tobias
Thanks for your comments and for pointing out the Intergrated Systems Model purposes by the Lee’s
This is great to follow but still my argument is the SIJ is not that often a problem or a cause of pain, the provocation tests are rarely positive so I question are we looking to hard for something that just isn’t an issue when other more important and fundamental areas need addressing and not over looked worrying about the SIJ?
Thanks again for your comments
Cheers
Adam
Adam,
If your clients are primarily athletic men, your claim may be true. It is however quite common to have SI, hip and pelvic girdle issues or combinations there of with post partem and middle aged women. I don’t ever look at the SI in isolation, because the solution is rarely isolated, it gets torqued or becomes unstable when the stressess of the kinetic chain are not balanced through the pelvis and the rest of the body. Once functional alignment and tone is balanced, the SI strain resolves.
I like the Lee’e perspective on considering the whole body alignment vs segmental perseveration. This is also the focus of Aston Kinetics though with a more functional alignment.
Their approach in palpation assessment of the SIJ is the same as use in the more traditional view. I have read their books (Pelvic Girdle, 3rd and 4th editions). They have a broad view but their palpation principles, basically, are the same of what is around there. The books are great, by the way.
Respectfully,
Claudio
Hi Adam,
Enjoyed the discussion surrounding your post. My conclusions in evaluating the research and my own clinical experiences is that due to lack of validity, SIJ motion testing is clearly flawed. When we palpate during movement we are clearly not evaluating SiJ motion. The size of motion at this joint and overlying tissue etc make this highly unlikely. Does this mean tests such as gillet or forward flex are not useful?
Maybe if we move away from orthopaedic style testing in which a positive test suggests the likelihood of a target condition and rather evaluate how an individual is coping with the demands of movement. Touching toes or lifting the knee above the waist appears to me functionally relevant, especially when these movements elicit pain. Observing symmetry of pelvic/innominate motion, weight shift, stability all provide clinically relevant information, not necessarily regarding ‘what’ is painful but more about ‘why’ it may be painful. An anteriorising innominate during forward flexion may indicate a restricted ipsilateral L5-S1, a restricted contra lateral hamstring or something else entirely.
Issues with inter-rater reliability pose even greater questions, I feel I have good intra-rater reliability and working in A profession that encourages you to trust palpatory findings it will take a bit more soul searching to throw palpatory information out quite yet.
Determining ‘what’ is painful can be more straight forward as Laslett’s work demonstrates, but finding the pain generater does not tell you ‘why’ it is painful in a patient centred approach.
Thanks
James
Hi James
Thanks for your very informative comments.
I agree that this post is only about determining IF the SIJ is a source of pain not the WHY, but the IF should be the starting point for all Ax and Rx for the SIJ, if no pain then it really doesn’t matter in the innominate is anteriorly, posteriorly or any other way rotated, shifted etc etc, and it is from my experience that the SIJ very rarely gives pain when put through these provocation tests, even when I suspect it as a source.
The SIJ just doesn’t cause that many problems, again in my opinion and that of some research (not all I hasten to add) so the idea of this post was to raise awareness of the best way to determine IF the SIJ is painful before you dive in with palpation to fix something that doesn’t need fixing
I again appreciate your comments on inter and intra reliability and I’m sure a therapist of your experience has excellent intra reliability but what use is that if the mechanisms of treatment you give make either no difference or are based on incorrect findings.
I do understand that the sense of palpation is an art and cannot be fully explained or measured by science and experiments, but we have to be careful and critical about what we can feel and what we can imply from this feel. It is my opinion that way too many therapists get carried away without critically reflecting on can they possibly feel what they think they can feel.
Thanks again for your comments and I’m sure the debate will continue and continue
Regards
Adam
Adam,
Just got onto your blog. Smart Dude and great topics.
Keep up the good work.
Conor
Another great article you Ham Fisted Numpty, maybe a change of twitter handle coming up?
I have never liked the fact that to many therapists rely on palpation and then give a grand diagnosis and continue for many weeks along what could be a wrong diagnosis and take money from the client, they never appear to stop and reassess when the client is showing no signs of improvement. This goes back to your critical thinking. IMHO we should all be asking are we doing the best for our client.
Ha thanks Stuart think ill stick with one I’ve got… For now
You’re spot on thou with what you say mate
Cheers
Adam
Another good post, and thoughtful like always. I think you brought up arguments ive seen in conferences around the world. Can you feel the SIJ? and i also have the same argument with myself. But i reason, even if not, well in our profession, the mind is powerful, if the patient believes whatever you told them, then likely chances are if you do something to correct what you told them, then it will have some impact on the issues. But like always follow the processes of re-assessment and continue….
Adam,
Very good article. My experience with the subjective nature of these tests mirrors yours.
I have other issues with the tests you mentioned.
Firstly, given that the SIJ is an inherently stable joint and that part of the joint is fibrous and part is synovial, I have always thought that it would require something traumatic to injure such a structure.
Secondly, patients will change their movement according to what is least painful and differences in “SIJ movement” on these tests can be due to pain elsewhere. I fail to see how any of these functional movement tests are specific to the SIJ as they involve the entire lumbopelvic region.
Hi Adam. Good thread and discussions here. I teach Integral Anatomy dissections in the UK with my colleague Gil Hedley and at Imperial College. I focus on challenging the conventional anatomical models and views, one of these being SIJ movement. The psoas obsession is another, but that’s for another time.
I have dissected hundreds of cadavers, preserved, soft fixed and fresh and the level of movement in an SIJ in all of them? None. Can you feel it move in any assessment? a) I doubt it and b) I hope not.
Andre Vleeming has written extensively about this and presented at the EIS conference last year where I was fortunate enough to also be presenting. The concept of the SIJ and the layers around it, present the joint as a fixed joint, particularly posteriorly where all the assessments are made. Anteriorly you are more likely to see a synovial space, but even there you have to dig. A lot.
The SIJ seems to serve as a transmitter forces, backwards, across and downwards. Looking at the Iliolumbar ligament is more revealing. The trouble with all this is that the assessments are made along the lines of traditionally taught anatomy, using muscle and bony relationships as the basis for modelling function and movement.
At this point I need to stop before I go off on one. But you are right, you haven’t felt it move and even in hyper mobility the degree of movement you are going to get underneath four inches of tightly packed connective tissue (barely a notion of any muscle there btw) isn’t going to relate back to making any of these tests make sense.
But if what you do helps people, then hold on to your practice dearly and your theory lightly.
Regards
Julian Baker
Hi Julian
Wow thanks for taking the time to read my blog, and please please do ‘go on one’ as you say, it would be great to hear some more of your experienced opinions on this topic, I could discuss this for hours, the myths and fallacys around what us therapists think we can feel and influence with our hands, knuckles or knees etc and the psoas release nonsense well that’s a months worth of discussion right there, I actually think I should write a blog on this, especially after the fiasco my critical sceptical views caused last year with some therapists.
And what a fantastic last quote, hold your practice dearly but your theory lightly!
Thanks again
Adam
See my post in the prolotherapy blog re: SI joint pain. I’m 56, I played rec ice hockey for 35 years, distance cycling but no running-based sports in the last 10 or so years and my SI joint started burning a few years ago. I think it was degenerative/arthritic based pain just due to wear and tear. Does the sports med community focus enough attention on the old athlete “wear and tear” problems? I think you will have a lot more younger patients showing wear and tear symptoms popping up than the past few decades since so many more people are participating in competitive recreational sports. And so I think there needs to be more attention to research and treatment options for these patients rather than telling them to stop doing what makes it hurt. I didn’t expect my low back to wear out at such a “young” age since I’ve always been in good shape.
When’s that next article being posted then Adam?
Love this one!
Jen
Hi Jen
I try to do a post once a month but it can be tricky to find the time with work and other commitments but thanks for your comments
All the best
Adam
I am still thinking locked SIJ and innominate upslip (what ever name it has) must be checked by palpation. Using provocation tests is about looking for stiffness and pain. Stiffness and pain comes years after the SIJ problem and they can come to back, buttock, groin, or legs or even to other side SIJ area.
I was a SIJD patient looking for help from many experts during my 15 years of pain. I love doing sports: running, swimming, gym. So I have always been very fit!
First my problem was stiff back, then pain in neck and shoulders. After few years I got pain in buttock and leg too. Then my middle back. Finaly my legs were weak, back was in pain, headaches, hand pain, finger numbness and finally I had to stop doing sports.
I visited many experts, doctors, physio, chiropractor, osteopath,… some of them (not doctors) told I have something wrong in pelvis but they didn’t know what to do. They just told I have stiffnes and I need to stretch. I did stretching, no help at all. Finaly I found an expert who palpated me and told I have left innominate upslip. Even my pain was on right side, stiffness on right side. He pushed it back down and immediately I felt the change in my body. My legs got strenght (no more short left leg), no back pain, headache gone, muscles starting to relax all over my body. Even my hands felt the change when my neck and shoulder muscles relaxed.
Since then I have been reading about SIJ malposition and interviewing hundreds of patients telling similar story. I understand many people have mispalced (locked) SIJ but not always pain in SIJ. Pain is in back, buttock, legs, knee or upper back. And only so few can help these poor people..
Toni
Hi Toni
With the greatest of respect the SIJ just doesn’t slip up, down or any other way, and a therapist most certainly can not push it back in, its simply just beyond any physical plausibility the body just doesn’t work this way, these manipulations of putting things back are just myths that have gained popularity due to marketing and mis-interpretation.
The SIJ is immensely strong and although it can move a small amount it doesn’t move enough unless there is significant trauma and there is no way ANY therapists can palpate it reliably to say its out of position, and as I’ve said it doesn’t get out of position, the joint can hurt for sure but is not due to it being out of position.
I am glad the treatment you got made you feel less pain and comfortable, but please believe me this had nothing to do with your SIJ going back into place rather lots of other wonderful, remarkable and amazing neurological processes that work to reduce pain after these types of treatment
I wish you well and kind regards
Adam
I understand your opinion. It is very common opinion. You have been tought that way. Still some experts disagree. I was lucky to find one. And I know many other patients he has corrected. You can contact him and ask his opinion and from where his skills come from. He is a licenced medical doctor of physical theraphy.
Acually there is a Facebook group with patients who have been in surgery where their upslip has been corrected. So they have evidence they had misplaced SIJ. Usually they just fuse that SIJ without correcting position and that is why it won’t give much help to most. But with some patients upslip is so clear they correct that too and you can see the change.
I understand palpation may be not reliable in many cases of mild dysfunction. But in many cases you can see upslip even without palpation.
And my SIJ didn’t hurt. I had pain in back, mid back, neck, leg and buttock. All common symptoms of upslip SIJ also called as innominate upslip, ilium upslip and by many other names.
Unfortunately many PTs and experts think upslip is not possible even when they see a patient with twisted pelvis.
Some experts also believe facet locks are not possible and they are always harmless and never cause any problems because no study shows they can cause problems or how to palpate them 😉
Thanks for answering
Toni
I add these. Vicky Simms talks about upslip. She has been correcting iliup upslips by surgery. Darren Higgins is teaching PTs about correcting it with MET-technique. Many others telling the same. But many other are mistaken and talk about SIJ pain, like you did. SIJ upslip and SIJ pain are different things because pain is usually on other side as Darren Higgind teaches in his course (Left side upslip causes right SIJ pain). Also my expert doctor told me that.
Vicky Simms and upslip: https://www.youtube.com/watch?v=d-jUtLfzM-c
Darren Higgins: https://www.youtube.com/watch?v=P15o5Y0kcD8
This might work too, John Gibbons: https://www.youtube.com/watch?v=5rE29vh79L0
Hi Toni
Thanks for your reply. But yet again I’m afraid I have o disagree. First many, many therapists do not think like me just the opposite, many believe that SIJs can move and that they can push them back in, even Tiger Woods physios http://thesportsphysio.wordpress.com/2014/08/09/a-tigers-sacrum/ and as you can see in the comments underneath my blog there are also many misinformed patients out there, who are led to believe that their pain has been addressed by pushing an upslipped, flared, rotated or torsioned SIJ back into place.
You are also mistaken in the way I was trained. I was trained to look for and believe in these SIJ misalignment’s by experts like the ones you have referred to. Unfortunately these experts only have opinion and conjecture and not evidence.
I’m afraid the YouTube clips you provided are only others opinion and not evidence, but neither are blogs like this one. Instead we have to look at robust scientific evidence for the answers. This recent paper http://www.ncbi.nlm.nih.gov/pubmed/24602677 is very enlightening, in that it accurately measured the movement of the SIJ in subjects with long standing SIJ pain who where also considered to be hypermobile (thats extra flexible) and even in this extra flexible group they showed that the SIJ only moved 0.5 of a degree, no way near enough to be considered out of place or upslipped and absolutely no where near enough to be detected with clinical examination.
Again please understand that I am not disputing that the SIJ can be a source of pain, I know they can cause people pain, and that it can refer pain into the back, buttock and leg, but it just doesn’t move out of place UNLESS you have had a significant trauma and damaged your ligaments or broken your pelvis such as with a traffic or sporting accident, but you wouldn’t be able to walk around if the SIJ was out of place, even a little.
I have studied this for years and despite being taught to think just like your experts I have come to learn that this is incorrect when you look at the scientific evidence and not the opinions of ‘experts’
There are many other much more rationale explanations for why the treatment you have had helps your pain without thinking it has put the SIJ back in place.
I wish you well
Kind regards
Adam
Thanks for your answer again.
I agree with you that some therapists think pushing SIJ can move the joint. Unfortunately they don’t do it well.
I have heard Tiger had some lock in his sacrum area. You mean he didn’t? I open my spinal locks every day to prevent muscle cramps. And I know most athletes use manipulation treatment for that too. Most of them do self-correction like I do. Even medical studies keep telling it is useless to do so 😉
Many patients have been in therapy where their ilium has been pushed and therapist have said it is fine now. Even it was not. I have been experienced that many times when meeting my chiropractors and osteopaths. They manipulate and tell it is done, even it was not. They just didn’t have skills to do it well enough.
I would say more than 99% of experts don’t do it right and they can’t correct upslip. They only twist pelvis and stretch ligaments/muscles. So it seems pelvis is aligned, but only for a while..
And that is why that one Pubmed study shows such a results as change of bone position is not done with manipulation treatment. Because 99% of experts can’t do it.
I have been many times in those treatments where a chiropractor uses chops to twist my pelvis, or PT pulls my leg, or osteopath uses chicago-roll and twists my pelvis. Then he is proud and tells me I was cured. Well, sometimes I felt like that for a moment.. but because he rieally didn’t do it well it was not true. After 15 years of searching I found first one with skills to do it. And I felt the change immediately.
I have been also diagnosed few times as hypermobile even my opinion is I am not hypermobile. Doctors just tried to explane my pain. I understand hypermobility and pain is not related. No evidence on that.
I am not sure what is the purpose of that hypermobile study and why do you feel it is enlightening? Some people are more flexible than others and it has nothing to do with pain. I think that is the result of that study?
Do you mean SIJ has to move a lot to be “out of place”? I think it is just the opposite. I was very stiff, as most upslip patients are. I don’t remember I have ever met a flexible patient with other ilium upslip. Some women with both iliums in upslip can be very flexible. But not all of them. Flexibility is not an indicator for upslip. I would imagine SIJ is not moving much all if you have upslip because it is stuck in “outside of its movement area”. And for those women, who look flexible, movement in forward flexion test is perhaps not from SIJ but from lumbar area.
SIJ as source of pain is what confuses many. Some believe it is some kind of “pain generator” and pain travels from SIJ to other places. Then they get injections for the pain in SIJ. They don’t understand pain is something else. I don’t believe SIJ can be such a “pain generator”. It sure causes pain and usually pain is felt in buttock, back, leg, hip, groins or somewhere else. But pain is not FROM SIJ, it is just malposition of SIJ that causes this pain by twisting pelvis, altering GAIT, getting muscles stiff and causing nerve compression. Same thing can happen in neck too: Nerve compression in neck can cause pain or stiffness to hands in different places depending what nerve has that compression.
Most of us have had big traumas as child play. Accidents, falling, slipping, hitting and many other trauma. It is no wonder some people get upslip as a child. Most people get pelvic asymmetry in child years.
br,
Toni
Dear Toni
I feel I am fighting a loosing battle, it is clear that your mind and thinking has been muddled and confused by the many so called experts you have seen with complete and utter nonsense and (please excuse my French) lots of bullshit
The point of the study I shared with you was to highlight to you that the SIJ just doesn’t move, even if considered hypermobile! It just does not get out of place up slip etc etc, if it did you wouldn’t be walking to see a therapist or expert, it’s as simple as that, if u can stand and walk your SIJ is in place
As I said SIJ cause pain to be felt and manipulations, even fancy clever ones from experts who can do it better than anyone else (which is more bullshit)…do NOT change the position of the SIJ… its just physically impossible… no human being is strong enough to produce enough force to do this, estimates in the literature suggest 2000+ newtons are needed to stretch the ligaments that hold the SIJ together, the most therapists can do is 350 ish, even the biggest strongest ones!
Also If we are being really accurate pain doesn’t come from any joint, muscle or ligament, it’s produced by the brain of course using information from the joint, muscle, ligament but ALSO lots of other information such as beliefs, memories, expectations, personality, mood etc etc all of these cause more or less pain to be experienced or perceived by you, not just the SIJ joint, not just the physical effects of the manipulation
As I said I’m glad the treatment you found helped you, but I will say it again, for the last time, the mechanisms by which you believe that it was achieved (ie expert manipulation putting the joint back into correct position) is just not correct…
Believe it or not, its up to you, please just consider what I am saying, as a so called expert in this myself, but let’s leave this discussion here now or we could go on forever!
Kind regards
Adam
Toni is everything that is wrong with Physiotherapy. Although I enjoyed this exchange 😉
I enjoyed it too. I think Adam’s patience is amazing. As I think Adam has shown quite clearly, the SIJ can indeed be painful but not due to a misaligned position, unless you have been in a major accident and can’t walk. Also, I feel like a lot of the people commenting THINK they have SIJ pain, either because the pain is located in the area of the SIJ joint or because they have pain in areas that are commonly associated with SIJ pain distribution. Thanks for this interesting diskussion!
Nice little collection of SIJ posts Adam!
As a student I often come over in cold sweats whenever I think of SIJ assessment and management
A. Because we covered it for 20 minutes in a lecture once, got shown the FABERS and Stork test and it was never to be discussed again.
B. I always had the impression it couldn’t dislocate (like yourself) and that palpating it etc. would not do much help.
I’ve never felt one move and still, like you mentioned, don’t feel there’s much evidence for the whole “popping your SIJ back into place” thing. How do you tend to manage SIJ pain in most patients (obviously all are different) are there any first ports of call you’d use to try and reduce symptoms effectively?
Thanks as always!
George
Hi George
Simply put if I think the SIJ is an issue I look to improve is capacity to stress, strain shear etc in all directions. This is best achieved with a graded exposure to movement. Sounds complex, but its simply movements and exercises that hurt a bit but not too much. As you said which exercises these are depends on the individuals pain and ability
Cheers
Adam
Hi Adam,
Thank you for your blog / twitter / articles, you are a breath of fresh air in the world of physio, you are the new order, hopefully!
I started my training in 1977, back then we had a twin set and pearls matriarchal membership that was tiresome beyond belief.
I have several things I would like to discuss /comment on, and I will admit I first wrote about all of them but I do not think that is the spirit of twitter, or any kind of blog, so for today I have promised myself to be specific.
I have read with great interest your article on the SIJ, I agree with you, I have read more Bullshit about this joint than any other, as a result of this I have decided rightly or wrongly not to listen, I know that is not in the spirit of evidence based practice, but in this case the evidence is little, spouted by people blessed with little lateral thinking and poor conjecture that is driven by what they know or think they know about other structures of the body.
I would like to list what I feel are short comings of the literature.
1. Nowhere else do we look at joints in isolation? We need to consider this to be a complex. The Lumbo-sacral lower limb complex. Some of the muscles that are involved in force closure also laterally rotate the hip and control pronation, that’s a long way off. It should in my opinion be examined when we look at all of our lower limb patients and also some of our cervical spine and shoulder complex patients.
2. This is a unique joint anatomically. Does it have it have a unique function? I think it does.
3. It has movement that appears to count for nothing. Nature has a habit of not doing that. What does it count for?
4. It and its controlling structures that force its closure are an integral part of the kinetic chain, like no other structure. So consider the kinetic chain, all of them below the shoulder.
5. Suck it and see is what you endorse, this is called Practice based evidence. You will never achieve this with Evidence based practice. The evidence is poor; we have examined too many cadavers without a lateral thought.
I agree that active exercise should be an integral part of SIJ rehab, but not strength work, control is the order of the day, the assumption that if you can stand and walk you’re able to control the SIJ or any other joint for that matter is more bullshit. More power will produce more of a problem unless it is controlled and indeed balanced throughout; increasing the tension / strength in one portion of a tensegrity structure does not improve the strength of the structure, if anything it weakens it. So any old exercise could worsen the thing, but as long as you use Practice based evidence then that is fine.
I am always disappointed with the use of Cadaver experiments, used to try and demonstrate the structures behaviour, we do not have the force available in our hands to move these fukcnig things, our body does (in my opinion) so do not use these research projects they are nothing short of irrelevant, I was disappointed to see you fell into that one.
Or maybe I should give you the benefit of any doubt, maybe I am a little slow and your message is these cadavers mostly have an asymmetrical pelvis and it was not the cause of death, they appear to of lived with it, so we should ignore it, I think probably the latter, sorry.
When examining patients we should be looking at symmetry! But not of position, or range of movement, but of control. So do not worry as to whether you can detect movement, or judge position whether it 2mm or 10mm, concern yourself with control in similar measures right to left, possibly front to back?
The modern approach to Physio has led to expressions like “The tissue is not the Issue” and “The brain decides the Pain. With the SIJ “Improving the range has little to change”.
I almost forgot, what is unique about the SIJ?
Well positioned in the centre in our gravity and at the intersection of all the lower limb kinetic chains, with links to the upper limb chains, I believe it is a torque detector, the amount it moves is irrelevant, as long as it does; it is a sensory organ.
I cannot prove that and I do not have the wherewithal to study it, but all good science begins with a working hypothesis, science does not begin with evidence of proof, that has to come. So bring on the interest, the research hopefully will follow. In the mean time we have to live with the embryonic science of practice based evidence just like you suggest.
Evidence based practice is of paramount importance, however we should not follow it like it is a religious cult, we should not be worshipping on its alter, it should not be our guiding light into the future, it should only be our present. Blindly follow the path of only doing what has tried and tested and we will stand still as a profession (we will all be dinosaurs) unless we use the imagination of practitioners who are prepared to think outside the box and try not to ignore the obvious, even Gray described this joint in its own classification and we didn’t catch on, we have done what has been done to every other joint we have meddled with.
I believe the reason for that is because we have applied our conjoined middle-class attitude of, we know it all to the potential learning.
In the 40’s Ghormley and in the 50’s Solenen both stated that the SIJ was without movement, a belief shared by James Cryiax and followed blindly by the then future dinosaurs. Let’s not make the mistake of blindly following again, I will follow the evidence and practice with it when I can see it, but I refuse to if I think its Bullshit; that is what I like about your blog, that is what you seem to say about stuff, I do not agree with 100% of what you say, but you say it in a way that I enjoy and relate to.
Thanks again for great work.
Rob Jones MCSP Old but not extinct yet, think Eusuchian
Great article and evidence-supported as always!
If you want to know how to perform the cluster of van der Wurff or Laslett, feel free to check our our YouTube channel at: http://www.youtube.com/physiotutors
– van der Wurff: https://www.youtube.com/watch?v=-L1i6GU39eU
– Laslett: https://www.youtube.com/watch?v=fbjXmM0qL3g
That´s a bit easier than in the link you provided!
Cheers,
Kai