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…
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