What is the best way to assess the Sacroiliac Joint?

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.

sacroiliac_joint-247x263

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

SIJ pain map 1

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

  1. Gaenslen torque test
  2. FABER's (Patricks Test)
  3. Femoral shear test
  4. ASIS distraction test
  5. 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

 

 

 

55 thoughts on “What is the best way to assess the Sacroiliac Joint?

  1. 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 https://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

                • 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!

  2. 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

  3. 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

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