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. 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

  2. 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.

  3. 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

  4. 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

      🙂

  5. 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.

  6. 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.

  7. 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

  8. 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

  9. 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

  10. 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.

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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.

  16. 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….

  17. 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.

  18. 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

  19. 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.

Please leave your comments here...

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s