From this article, one or two people have asked how do I treat a painful SIJ if I do come across one, so this is the subject of this post. Now again I’m sure this will create some discussion and some controversy, so please feel free to comment and give me your experiences and insights but please keep it personable, for some reason the SIJ seems to get therapists fired up more than any other area, I’m not sure why???
Ok let’s go…
So the first thing to say here is that I haven’t treated that many painful SIJs, I am not claiming to be a SIJ expert, far from it as I can confidently say I could count on the fingers of one hand (ok maybe both) how many SIJ problems I have ‘treated’ in my career due to there rarity!
I do however get lots of patients telling me that they have been told they have an SIJ problem by another therapist, some have even been told that their SIJ is out or alignment or unstable, which is complete an utter rubbish, and really annoys me that a so called healthcare professional uses these inaccurate and fear inducing terms.
Normally a quick assessment using the pain provocation tests I mentioned in my other post very quickly rules out the SIJ as a source of pain for nearly everyone I see. In my experience it is normally something in the lower back generating pain to be felt around the posterior pelvis, and often there is no firm or conclusive source of the pain, whats call ‘non specific low back pain’ and this can be frustrating for both the patient wanting a diagnosis to explain why it hurts, and also for the therapist wanting to give something technical as a diagnosis, and to treat, and this is why I think the SIJ gets labelled and blamed way too often! Therapists love a big impressive sounding technical diagnosis, it makes them feel they’re using their training and skills to detect something complex and complicated, but unfortunately it’s just not!
A recent study by Cohen et al 2013 states that the SIJ accounts for between 15-30% of all low back pain! I argue, because I like to, that it is much less prevalent, this maybe due to my ‘normal’ clientele being slightly different from that in Cohen’s study.
Ok! So what do I do if I have found a rare SIJ causing pain?
Well simply, I get them all doing exercises, great thanks for reading….
WHAT… WAIT is that it??? I don’t I poke, prod or manipulate them, don’t I give an anterior innominate rotation thrust or a posterior torsion mob here or there….
Well, no I don’t, I cannot remember the last SIJ manual treatment I gave, if I do decide to do any manual therapy, its NOT to correct or attempt to change or alter its position and its definatley not to ‘loosen’ or free it up, let me explain why.
Firstly if we look at the anatomy of the SIJ closely, as in this paper by Vleeming et al 2012 does very well, we can see that the congruity of the bony surfaces, combined with the many strong ligaments that cross it, make the SIJ a very, very stable joint, it has to be, it transfers a lot of force and load from the legs to the trunk and visa versa, this is termed the SIJs form closure ie its shape and structure.
However, the joint also requires the contraction of muscles around it to help control the small amount of movement that is available to allow the effective transfer of stresses across it, this is what’s called force closure, read more in this paper from Wingerden et al 2004 on that.
So in summary the SIJ wants to be stiff and stable but it also needs to move a teeny tiny little bit occasionally.
Now the two main reasons why the SIJ is thought to cause pain is either due to excessive movement causing shearing forces between the joints articular surfaces, and I use the word ‘excessive’ here with caution, as the SIJ doesn’t move much at all, on average about 2-3 degrees, thats about 3-5 millimetres of movement, but it is still thought to be enough to create irritation.
The other reason its thought to cause pain is that the SIJ becomes too stiff, stuck or jammed and the little bit of movement that it is supposed to have isn’t available and so creates pain.
But are these theories correct!
Now, Greg Lehman an excellent physio, chiropractor and an ex researcher, has shown me that we can’t say excessive shearing or extra movement at the SIJ causes pain. (Follow Greg here on twitter, and go visit his excellent site here)
For example this paper here by Damen et al shows that SIJ laxity, which is common during and after pregnancy, isn’t correlated with SIJ pain, they found pregnant women with severe pelvic pain had the same amount of laxity as those no pain, so proving we can’t just blame SIJ laxity for the pain!
Next, the strength need to produce force closure by the muscles around the SIJ are not very much at all, and so cast big doubts on the theory that muscle weakness can leave it vulnerable to laxity and shearing forces. Actually most muscles around the trunk when they activate even gently create enough force to close the SIJ as shown by this study here by Richardson et al showing that if they can stand up they can produce more than enough force to stabilise the a SIJ!
So if not laxity, shearing forces or weak muscles causing the SIJ pain, what about it being stiff, getting stuck or not moving enough?
Well I question how is this is even possible, and if it is, how do we know its stuck? I have already discussed in my other SIJ article that there is no way of palpating or feeling a SIJ move or not move so we can never tell if its stuck, and a too stiff SIJ just doesn’t make sense to me, the SIJ wants to be stiff and rigid, if its too stiff why would that cause pain? And how on earth does it become stuck as some claim, does something get inbetween the joint, highly unlikely in my opinion.
So if not due to excessive movement and not due to it being stuck then why does then SIJ cause pain? Well simply I think its due to plain overload and excessive forces across the joint that it can’t handle, so nociceptive nerve endings around it complain, it’s as simple and straight forward as that, no excessive this, no stuck or stiff that.
So how do we treat it?
Simple, as I said earlier, exercises, to build up the SIJs resitance to take an increased load by increasing the soft tissues capacity in and around it. Which muscles you choose to do will be based on individual severity and irritability and their pain provocation patterns, skill levels and goals but in a nut shell I dont think it matters too much, as we know from that earlier Richardson study all the trunk muscles have a role in producing SIJ force closure. But usually in my experience the muscles of the posterior oblique sling are the ones lacking, most people I meet are weak in the posterior chain and so these are the ones to focus on more, such as the Latissmus Dorsi, Hamstrings, Glutes and of course the large powerful Erector Spinae muscles all of which act on the thoracolumbar fascia.
Image courtesy of saveyourself.ca
How you go about this is up to you, it is obviously guided by the levels of pain the patient is in, if really sore, then non weight bearing strengthening of these muscles can be used to start with until the irritation settles combined with other pain relieving modalities (which I will come onto in a second).
If they’re not too painful then progress them into weight bearing exercises, progressing them until you can get them exercising under extra load and resitance, in different planes of movement and variable speeds dependant on what that patients goals and tasks are, I not going to be giving all the exercises possible or we will be here all day, but exercises like bridges, deadlifts, kettlebell swings, lat pull downs are all great moves.
But what about manual treatment?
Well I’m going to throw in a controversial bomb here and say that although you can apply manual therapy treatments, it really doesn’t matter in my opinion WHAT manual treatment you do for a painful SIJ!!! (I await the backlash)
Yes you can apply an anterior or posterior innominate rotational mobilisation or a scaral thrust or two, even give some ASIS distractions or compressions it doesn’t matter as there is NO physical way you are going to make any structural difference to this emmensly strong and stable joint with your hands, steam roller yes, hands no! Even if you do affect the SIJ a tiny bit, as soon as the patient moves to get up off the treatment couch and stand up it will go back to where it wants to and started off in the first place.
Now before you go of your rocker with rage as I’ve just ridiculed your training and skill, I’m not implying manual treatment of the SIJ is a waste of time, far from it, it does seem to reduce the level of pain felt for a grumbling SIJ, a little bit, for a short while.
But what I do argue with is those that feel they can assess which method or direction of manual therapy is best based on physical assessment and palpation tests,
Simply put it doesn’t make any difference what or which way you bounce, rub, push, poke or pull on an SIJ, its not the physical effects to the joint that matter, its the descending neural pain inhibition effects that do!
But surely there is some role for the direction of pushing or poking or even the exercises we give depending on what you feel and observe the persons posture or degree of pelvic tilt/rotation to be?
Again I’ll say it NO, it doesn’t matter, even if you think you’ve found someone standing with an anterior rotated innominate or a posterior rotated one, or one higher than the other etc etc, as using these bony landmarks to guide your reasoning in deciding on an SIJs position is unreliable and is no more than palpation fantasy as neatly demonstrated by this paper by Preece et al 2008 who found wide normal anatomical variation in the angles of the ASIS and PSIS.
So what do I do, well if I decide on a rare occasion to give some manual therapy on an SIJ, I simply pull and poke it with no real clear idea or direction in mind, I do it on trial and error basis, push a bit this way, get them up and moving a bit, ask if it feels any better, no, ok get them back down, push the other way etc etc.
Now some say that I use this method due to my lack of skill or experience or that I haven’t got the expert super duper ‘feely’ hands or the extra sensory perseption skills that other therapists have! I say nope that’s aload of crap, it’s just me being realistic and honest in realising that no-one and I mean no-one, can assess clinically and tell which way a SIJ needs to go or which way is going to help! So I say why limit yourself and possibly miss helping someone just because of some delusion of skill, some rubbish tests and personal pride, I say push that bugger in all directions until something feels better for the patient, it’s that simple!!!
So in summary I’d argue the only way to treat a true and rare painful SIJ is with exercises. The exercises you choose I don’t believe make much difference but should be chosen depending on the level of your patients pain, irritability and skill. They want to be progressed into loaded, multi directional and varying speeds, dependant on your patients goals, tasks and activity.
Manual therapy can be used to relive a painful SIJ but not on the pretence that you are affecting the physical properties of the SIJ or that you can only try it in one direction after an assessment as you can sense or feel the dysfunction.
Finally does assessing the posture of the SIJ pelvis and lumbar spine of an individual really help us, or does it just place confusion and doubt into the patients mind for no reason when there is scarce evidence to say that any type of posture is of greater risk or worse than any other?
Food for thought I hope???
Once again thanks for reading