A Tiger's Tale… or rather its Sacrum!

Hi Adam,
First things first.
Thanks for the insightful blogs.
Not only are they up to date with the latest credible evidence and offer an informed perspective, but your wit makes for a great , fun read !
I am hooked !
When I heard the bit about Wood’s “sacrum popping out”, I was secretly hoping it would be an error of interpretation on Tiger’s part. That a reputable member of the medical fraternity would make such a statement was simply too plain embarrassing to be believed. And still it was from the horse’s mouth, no less. A tad sad.
Any chance of a write up on the spine ? Shall be looking forward to it.
Thanks again,
Tanvi

Hi Adam,
Another great blog again. I do have one question however. Even though I’m fully on your side of the fence with regards to the SIJ not “popping out”. I can only presume that the medical team did manipulate his SIJ/Lx spine and prescribed NSAID’s. Would it be fair to say that the combination of Manipulation and NSAID’s were the key to his return to play (I know your not a big fan of manips).I’m curious as to your thoughts on how tigers managed to complete 36holes without too much viable issues.
Cheers
Alan

Some great points here Adam, thanks for sharing them.
Quite rightly, sacrums don’t just pop out (nor pop back in).
As therapists, we have a responsibility to be delivering the most evidence based treatment strategies and these often hinge around a strong therapeutic alliance. O’Sullivan uses a metaphor around treatment effects similar to using a syringe and fluid delivering an injection. The non specific treatment strategies (such as a the therapeutic alliance) are like the needle, an essential part of the delivery of the specific effects from the treatment itself. If the specific effects of the treatment (in Tiger’s case a manipulation) are given an explanation which is faulty by a therapist with whom he has a strong therapeutic alliance, (in his case as a reposition of his sacrum) these treatment effects act, instead of a placebo, like a nocebo. It fuels a sticky belief system which influences behaviours and fuels a pain cycle on many levels. In this way, as therapists we have a responsibility when we do have an effective and influential patient therapist relationship is to ensure we are facilitating the recovery process rather than hindering it. Our message acts a powerful determinant of the end point of treatment This concept has been brilliantly discussed on the BJSM podcast recently by Roy Moynihan.
Tiger’s belief system is likely to generate a lot of fear around movement (kinesiophobia) and there is evidence in the literature to suggest that such fear of movement can generate an increase in trunk stiffness (due to muscle guarding). Which in turn could affect his golf swing and his pain.
Having a long line of golf addicts in my family, I am well aware of the well documented troubled private life of Tiger over the past few years. I can’t help wonder what effect this level of stress and arousal has had on his sleep habits and the other associated psychoneuroimmunological repercussions on his pain response.
My concern surrounding your post is this. I don’t think the answer for Tiger is a good honest strength and conditioning programme. Or at least not initially.
A key part of Cognitive Functional Therapy assessment process, as pioneered by Professor Peter O’Sullivan and team, focuses on determining the pain mechanism driving the individual’s pain. This clinical reasoning process can then lead the treatment strategy.
Tiger’s story around his pain needs to be heard. We can all hypothesize about what is driving his problem and what his rehab should entail but this is purely guesswork of course.
Any history taking has to include a screening for all the risk factors for persistent pain issues which include early life stress, history of depression, smoking, sleep deficit etc.
And an observation of pain behaviours that he may have adopted (I have certainly seen a few of these when watching from TV). What catastrophic thoughts is he having? Has he developed fear avoidant behaviours? It would be interesting to see how hypervigilant he is around his back. His future career is on the line.
Body schema issues may also need to be explored. Ask him to draw a bodymap of his back and how he perceives it to look. A Physiotherapist experienced in working with mindfulness based strategies may well find something to work with here.
Not forgetting the biomechanics of his golf swing and how his postural habits in other everyday activities as well. Never forget the bio (I 100% agree with you that one Adam).
There are so many factors that need to be assessed and I certainly haven’t listed them all here. I am sure those trained in the CFT approach, amongst others, could continue this list almost endlessly.
However, I do wonder, as a therapist who has used the evidence based Cognitive Functional Therapy approach as developed by Professor Peter O’Sullivan and the pain-ed team for sometime now, whether the answer to Tiger’s problems may lie in his breath. It is certainly something I include in the assessment of every back pain patient.
Does he anticipate pain by bracing? Has he been taught the dreaded isolation of TAbs in neutral or has he adopted a pre-tensing of his abdominals automatically as a protective movement strategy? Does this then have an effect on his intra abdominal pressure increasing lumbar stiffness (we are going full circle here) and loading of pain sensitive structures in his back that have been already sensitised by a heightened nervous system arousal?
There, I have got it off my chest now.
Start with the breath. In his aggravating postures and positions. Dare I say make it functional?
From spending time watching Professor Peter O’Sullivan work during his workshops in the UK, and using the CFT method in my own work, I have come to realise that it can be the most simple treatment strategies that can solve the most complex of problems. I am continually amazed how quickly change can happen using this approach. Strength and conditioning training will no doubt follow but these other factors are likely to need addressing first.
Keep up the good work Adam.
Helen Preston
(twitter handle: @PrestonsHealth)

Great blog Adam, and a brilliant response by Helen considering so many factors we all should be considering in daily clinic/outpatient life. Great work guys

Thanks for your reply Adam.
I totally hear your point about athletes wanting to “do” something rather than talking but Classification based Cognitive Functional Therapy (CB-CFT) is not Cognitive Behavioural Therapy (CBT) It is not just talking.
I would highly recommend this editorial in the BJSM as a reference point for your readers to learn more on the CB-CFT approach: http://bjsm.bmj.com/content/46/4/224.extract?sid=8f0bb2ab-ecc6-427d-b085-4c5464d4f87c
Being married to a double Olympian myself, I have been lucky enough to observe first hand the culture around both athletes and therapists towards rehab over many years. Elite athletes often talk about mindfulness based concepts (such as being in the now) with regards to their performance, it really isn’t anything new. However, rarely do I hear of it talked about in sports injury rehab. Targeted mindfulness (as mentioned in the above text by O’Sullivan) can be a very powerful tool in facilitating movement behaviour change as well as pain.
As you point out, sometimes the hardest thing for a physio is to do nothing. It can be even harder for the sportsperson. But maybe it is exactly what their nervous system needs. “Being” rather than “doing”. It is important that we don’t let our own bias’s get in the way of outcomes for our patients.
CB-CFT is a behavioural approach and its use of targeted mindfulness in appropriate patients is always applied in a functional way. The beauty of it is that patients can experience change there and then. And the proof of the pudding is always in the eating. If they feel better immediately, then they get it. And having the drive that makes someone an elite sports person often means they can master it quicker than other individuals.
I do agree that you can implement a lot of this into more traditional S and C training as you describe. My point is that sometimes we have to accept that initially it has to be learnt in a relaxed manner and with isolated focus. We have to become more comfortable as a profession with the idea of not always “doing ” something to our patients. Whether that “doing” be manual therapy or exercise.
We have to make our treatments totally patient centric and individualised. I know we agree on that.
Best Wishes
Helen
I read this today and, although not sports specific, I think provides something around the concepts of mindfulness and health for the sceptics (thanks to @painphysio for the link) http://www.independent.co.uk/voices/comment/a-pill-may-help-stave-off-death-it-doesnt-teach-you-how-to-live-9658215.html

Lovely Article!!

Yes this was an interesting one, was following all the tweets. On one hand, yes, it’s complete bollocks about the sacrum “popping out and pinching a nerve”. But then again on the eve of a major tournament the pressure to do something quickly with him must have been very high, it’s no excuse, but I doubt anyone was going to sit down with him and say “tiger, we need to talk about your feelings and the real reason your back is sore”. I daresay Tiger chooses his medical team and even if someone had started to dig a bit deeper into things I think they would have been sent packing pretty quick. It sounded like he wanted to hear something simple, I.e. Sacrum popped out. Reconceputalising the patient can be the hardest thing no after how much science you have behind you. Lastly the strength and conditioning theory (as in Tiger needing this)opens another can of worms , in that it implies weakness causes pain. All good fodder for discussion.

Thanks for taking the time to reply Adam.
I enjoyed the discussion in response to your blog.
That’s one reason I look forward to reading it !
Well, about the spine. Wouldn’t know where to ask you to start.
It’s just that I have read such splendid pieces from you on the shoulder and the knee and all the while getting all kinds of spine pts, so just wanted to know your general approach towards a spine pt – cervical/lumbar. Because last I heard the core no longer counts for much ! So I guess its just strength and conditioning now. Along with correcting asymmetries, which again, has been questioned !
Thanks again for your time,
Regards,
Tanvi
Thanks again,
Tanvi

I must respectfully disagree. Since approximately 2008 this incorrect thought about the sacrum not being able to pop out or dislocate has been dis-proved. It is very slowly seeping through to the mainstream medical and physiotherapy world.
Professor Begnt Struesson had published papers on it and sacrum fusion and other thechniqes
such and ifuse and DIANA operations have been undertaken since at least 2008. There is a whole community of approx 500 patients around the world in my sacroilliact joint dysfunction (SIJD)support group who would also disagree and have been let down by years of misdiagnosis, pain and disability because the slightest mis-alignment of the sacrum can cause extreme pain (because it’s not designed to move) but does not show up on imaging. This is becuase the joint is so thick with ligaments and is like a ‘tongue and grove’ joint that it is nearlly impossible to show even a relatively large dislocation more than a new millimeters,
with imaging. I know becuase mine was dislocated on and off for 3 years and eventually it would lock in the dislocated position. I would literally get my husband and osteopath to push on it and suddenly it would pop back in and I could miraculously walk again- and this is the experience of a lot of people with SIJD.
There are now a handful of clinics around the world who treat it by aligning the sacrum
( this clinic I actually went to in the USA from Australia becuae I was getting so severe) this clinic aligned my sacrum properly and ‘popped it back in’ along with sports taping and strengthening program and I started to walk again from being in a wheelchair.
; There are also numerous patients who saw jerry hesch and miraculously came out of his 3 days of treatment walking becuae he aligned the sacrum and pelvis again. I have spoken to these patients personally. Jerry has also documented before and after his treatment of the sacroilliac joint on Utube. The sacrum can and does pop out in a small number of patients. Please stop having such a closed mind to this proven fact becuase it is very upsetting tonpeoplemwhonhave suffered from it for years with no recognition that they KNOW and can FEEL the joint is ‘out’ but practitioners like yourself make them feel like they are not believed and go undiagnosed for years being in pain and loosing more and more
independence the more disfunctional the joint becomes because the longer it’s left out the more the ligaments stretch causing it to stay out for longer and longer periods of time until it’s chronic. Also this is where prolotherapy is done in conjunction with aligning the sacrum. Prolotherapy is done to tighten the ligaments while the sacrum is ALIGNED and not dislocated.
Associate Professor dr Joanne Borg-stein of Harvard medical is an expert and also does NOT do prolotherapy unless the patient is also seeing a chiropractor or other health professional to align the sacrum while undergoing prolotherapy. I do hope information and future blogs can be a bit more open minded and medically current pertaining to issues related to alignment of the sacrum.

Well Adam, I feel it is terrible you call your self a sports physio when in this article you have BLATANTLY ignored MEDICAL FACTS, and by doing so have offended the hundreds of thousands of people living with sacroiliac pain. MANY people suffer from sacroiliac joint dysfunction (SIJD) which is a condition involving your sacrum, Illum, and SI joint. Have you ever heard of hypermobility? Let me give you the definition: “Joint hypermobility syndrome is a condition that features joints that easily move beyond the normal range expected for a particular joint.”
(http://www.medicinenet.com/hypermobility_syndrome/article.htm)
So YES the SI joint (and connected muscles, ligaments and bones INCLUDING your sacrum) can move beyond what is considered “normal range of motion” and further more can absolutely be FELT and is excruciating pain. Also too little movement can cause serious problems: “Sacroiliac joint dysfunction generally refers to pain in the sacroiliac joint region that is caused by abnormal motion in the sacroiliac joint, either too much motion or too little motion. It typically results in inflammation of the sacroiliac joint, and can be debilitating.”
http://en.wikipedia.org/wiki/Sacroiliac_joint_dysfunction
Tell me, if nothing can really go wrong with your sacrum then why do surgeries exist to fix a problem that to you is “non existent” for example the iFuse procedure, fusion of the sacrum to the illum and more. Here are a few good reads you might consider before you go dismiss and OFFEND thousands of people who live in pain with this condition on a regular basis.

ALSO why are you deleting the negative comments? Is it because all of us SIJD sufferers are proving you wrong?

As a patient going through Sacroiliac Joint Dysfunction and almost a year of Prolotherapy I was quite flabbergasted at this article. Still in 2014 there’s this “unspoken agreement” that the sacrum cannot move and that is untrue. There are hundreds of scientific articles & studies that prove it does not dislocated like a typical joint but there can be significant movement within the joint. The sacrum & iliums do not align like a jigsaw puzzle piece, causing extreme bone on bone pain. With the right muscular and ligament circumstances the sacrum can have many patterns of nutation. This cannot be viewed on imaging and it leaves thousands of patients seeking help for a problem that can only be felt through multiple spring tests of the sacrum, checking ilium alignment and several other orthopaedic examinations. There are surgeries to help bedridden patients and Prolotherapy along with alignment & physiotherapy is the only option in Canada to help chronic SIJD like I have. Please take the time to educate yourself in regards to this blog post. It would be great to see an updated post validating us patients fighting tooth and nail to find doctors & therapists to help us through such a debilitating injury, especially in the chronic stage. Open your mind and please visit (advertising link removed) for information on SIJD. The Hesch Institute is a specific pelvic therapy clinic that focuses on sacrum nutation. Jerry Hesch offers classes all around the USA, spreading awareness through education of physio therapists. Diane Lee a pelvic health physio therapist & educator from Vancouver BC also has great information about this as well.
All patients like us want is recognition so we have access to the rehabilitative help we require. Many travel far and spend a lot to figure chronic SIJD out and in return gain back their mobility. This can be a severely debilitating & painful condition that can no longer be disregarded because imaging shows nothing wrong.

Adam, your article is misinformed and misleading. What exactly are your qualifications which allow to speak with such authority on a subject you obviously know little about.? For decades people have suffered enormous pain and disability caused by sacroiliac joint ligament injury and sacroiliac joint dysfunction (many of them women) for which they have been unable to obtain an accurate diagnosis and treatment. Within the medical community and the physiotherapy community there has been a perpetuation of the myth that sacroiliac pain, injury and dysfunction do not exist and are not treatable. I suggest you re consult pub med with an objective view to really understand the current state of thinking wrt sacroiliac joint dysfunction. A lot has changed. To get you started in your re-education you may wish to consult the following websites: (links removed by moderator for advertising)
So long as physiotherapists such as yourself continue to perpetuate the old wives tale that sacroiloac joint injury and dysfunction do not exist, people like myself and hundreds of others will continue to suffer without viable diagnostic and treatment options. Please, please take the time to educate yourself on the current medical knowledge before publishing articles such as this.
I look forward to seeing an update to this blog, retracting this mis-information.

I would ask that you do not remove the links in my comment which direct interested readers to not for profit foundations.

And furthermore, sacroiliac joint pain and dysfunction are ALOT less rare than you think. It’s these kinds of statements which do a huge injustice to those people struggling with this injury and very often chronic debilitating condition, many of whom are women!

US Army vet here with documented sacral movement and nerve impingement (and subsequent retirement after three years at Walter Reed). A dozen EMGs can’t be wrong 🙂 What Tiger experienced is commonplace for many SIJD sufferers, except that we don’t ‘return to normal’ after our injury. I think that everyone is taking offense to your wording and reading it as “there is no movement of the Sacroiliac joint” (which is not true), rather than “Unlike other vertebrae in your spine, the vertebrae in your sacrum don’t move”, which it true. Whether the actual movement is from the Ilium or the Sacrum is immaterial. As a viscoelastic joint, the sacroiliac can (certainly) become dysfunctional.

My SIJD came from pregnancy, not an accident. I went to 20 different specialists just this ignorant. When I mentioned fusion to one in paricular, he said, “isn’t the SI joint naturally fused?” *facepalm*
Look, I don’t know these other patients, so don’t assume we’re all from one clinic. All I know is the SIJ does pop out and you’ve said in this blog that is does’t (NOT that it’s very very rare). In your replies you’ve also said it has to be trauma related. Well I woke up with it in my eighth month of pregnancy. So I guess you can add “sleeping wrong” to your list of “very very rare” traumas that can cause hyper mobility. I thank God every day for my ortho who fused my SIJ.

Adam – it does not appear to me that the comments of the other posters are “ill-informed”. While it is possible that some may have misinterpreted you at some point, your blog posts and overall tone suggest that there is no such problem as sacroiliac joint dysfunction. This is the part that those who are suffering from this condition are having a hard time swallowing. I find it to be somewhat medically irresponsible of you to shun those posters when there is obvious suffering on their part. If your blogs are being misinterpreted, perhaps you need to clarify your point a little more and explain exactly what you mean without disregarding the very real existence of SIJD as a true issue. In fact, many of those suffering are post-pregnancy women who are already lost in the chaos of new motherhood and an extreme lack of understanding about the pelvis and sacroiliac joints overall. I have what you might call a “loose” or “unstable” pelvis and have suffered extreme pelvic and sacro-iliac pain for years (it is FINALLY improving due to some very intense and involved Rolfing and osteopathic therapy), and I have had my sacrum “go out” to the point I could barely move or walk, and then had it “reset” by an osteopath. Sure, it can “pop out” again after that manipulation, but the idea is to find and address the other musculoskeletal issues and imbalances that could be contributing to the mis-alignment and solve for the whole body so the sacrum is less stressed overall.
I know you think you have explained yourself in other blog posts, but my comment is that this particlar blog seems to be misinformed and alienating to those who are truly suffering. Being that this is a blog highlighting a famous athlete, people are more likely to read it and it really should be clear, within the parameters of this post alone, that SIJD is a very real problem for many – even if it isn’t a problem for Tiger Woods.

I find it almost comical that you keep lumping us all together like we are out to get you. I don’t know who these people are, but what I think most of these comments are saying is that in this particular post about Tiger, you pretty much state that there is no such thing as a sacrum that moves. Perhaps you DO clarify it in other blogs, posts or comments, but once the Tiger post has been read, the damage has already been done. At this point, my interpretation is that you are being a bit smug and defensive about the whole thing, which is unfortunate. This makes me glad I am not coming to see you for assessment or help. I have been blasted, negated, belittled and mistreated by countless practitioners already, so I don’t need to be poo-poo’d by you as well. Many of the people who have suffered with this ailment have seen NUMEROUS therapists, doctors and practitioners who do not understand the SI joint or the problems that can manifest around it. It seems to me like maybe you’d be better off saying that YOU mis-spoke or misrepresented something instead of shrugging off what is actually being said here…but that is just my two cents.

Hi Adam
Great blog
And thanks to the comments from those above who have made me laugh and entertained me in thinking that you can disclose the SIJ, top reading following by great banter.
There is a reason you have so many following your blog and agreeing mate.

Thanks for the blog Adam. Evidence based and exactly the kind of information health professionals should be spreading. Unfortunately the messages given to some of the “SIJD” patients by their health care professionals is what has worsened their suffering. I don’t blame them for their beliefs as they’ve been fed the nonsense by someone that they have trusted with their health. There is just no need for the personal attacks on you. I’d like to know how many of them still suffer pain having seen these experts and how much ongoing treatment they require. I’d also like to add that a Wikipedia link does not constitute evidence and that a dozen EMGs can be wrong as it is not a valid tool to measure SIJ movement.

Adam, from your responses, you seem to be targeting a certain type of practitioner that sells “snake-oil” cures for real situations that really should be treated by professionals, and for that I thank you. I think the place where you’re making enemies, albeit unintentionally, is with the flippancy (as someone else pointed out) of your response to the seriousness of SIJD. Most of us have seen well over 20 doctors (most of whom seem to want to fuse our spines interesting enough) who have been dismissive about the role of movement in chronic pain generating from the S/I joint.
Yes we are angry. However, I agree with you about the unfortunate use of phrases like “popping out” (what?) of the S/I, or “bones grinding together”… it certainly doesn’t do anything to further the cause! What we would like to see is more professionals who take this condition seriously so that we can get treatment (other than fusion) that’s covered by insurance. That doesn’t seem like too much to ask. This is a real condition, and many of us network with our PTs and Physiatrists to try to advance the public discussion about SIJD. We’re simply looking for allies rather than critics. Sorry if you take our anger personally, but this is a life-changing condition that simply isn’t accepted within the traditional medical community.

Wow…. long time reader. Kind of disgusted in how you responded to some “SIJ fans.” Derogatory. I don’t know what a “popping out” sacrum feels like, but I do know my sister suffered from this for 4 years after having her second child and it was, in fact, debilitating and saying your sacrum “pops out” is just Tiger’s easy way to appease the media and explain an injury in simple, “dumbed down” terms as we all know, it’s extremely complicated!
Let this injury happen to you.
You suffer from it for months or years and come back and write about the fact that it “does NOT move.”
Gross.

There is certainly a lot of learning to be done by physiotherapists, chiropractors and doctors on the topic of SI Dysfunction. I have been struggling with the condition for over 4 years now, and it was caused by a manipulation by a physio. He informed me that my pelvis was “locked” and this was causing my upper body pain in my arms and shoulders. He said I needed a manipulation of my SI joint, which I had never heard of. My only reason for the visit was the arm and shoulder pain. He was persuasive and so I allowed the manipulation, which subsequently turned my life into a living hell! The right SI joint became hyper mobile and I could not walk and suffered excruciating pain! And of course there was no help to be found at Emergency where they just send you home with pain killers. Doctors were no help. I had to do my own research to figure out what I had. This condition is no laughing matter, it is severely disabling, and that is why sufferers are angry when you speak so flippantly about it. The sacrum does shift and get stuck in painful positions, there is no doubt about it. Or in the case of hyper mobility the SI joint is not holding together and walking mechanics are totally dysfunctional. And the fact that a physiotherapist did this to me is unforgivable. I find the medical community is in the Dark Ages, they are so uninformed about this and people are not getting the help they need . LOTS of people!

Thank you again Adam and the other readers who have taken the time to reply for for highlighting some very key issues in the management of musculoskeletal issues, in this case the SIJ.
It is clear that there are some very strong belief systems surrounding this topic and it is clear that these are miles apart amongst the readers of this page.
Firstly, I feel I have to make it clear that I have every sympathy with anyone that who has pain. I have had both low back pain and pelvic pain (during both my pregnancies) so can speak from personal experience with empathy.
Secondly, I also have every sympathy with patients looking for a solution to their pain and find that there is an array of different HCPs offering very different explanations for their pain, which is confusing and I am sure disheartening. I can understand the anger that brews up inside when someone questions their current line of management as it holds an aspect of hope of an end to their problem and hope is a very important factor in any rehab programme.
The issues raised highlight that there are very different paradigms that HCPs work under. Some work under a biomedical bias where structure is blamed as the source of the pain (such as the SIJ clinic that has been discussed by some of the readers here) while others work under a biopsychosocial model that incorporates an understanding of the multidimensional nature of pain science when considering the pain source. This is the paradigm that Adam and myself and many HCPs work under. The majority of those that work under a biopsychosocial approach now (if not all) were trained under the biomedical model and found that it did not hold the answers to the majority of their patient needs, hence over time, they have found another model to work under. For me, it was a gradual process over the 18 years since I qualified.
This model is fundamentally different from the biomedical one as it gives the key to controlling the pain (in this case) to the patient compared rather than the person who is delivering the treatment. While passive modalities (such as manual therapy, manipulation or even injections) may be used in this approach (this is what we mean by remembering the “bio”), the focus is more on exploring the reasons why someone has pain beyond the structure (in line with pain neuroscience literature) such as the points I describe in an earlier post in the blog. Treatment choices are then given to the patient to target the many different factors that lead to pain. If this way of thinking about pain is new to you, then this clip may be helpful
https://m.youtube.com/watch?v=4b8oB757DKc
Adam has been highlighting these issues within his blog for a long time and, while they are highly highly challenging to those who are stuck in another belief system, they do reflect the current state of evidence that is out there. It is important that both sides of this argument is heard. By all means question your current or future HCP’s reasoning as to why they are using the treatment strategies that they are, even ask for proof that the evidence they are using comes from peer reviewed, evidence based journals.
So, where to go from here for the readers that have so passionately argued the case for the specialist SIJ clinic?
If it is working for you, great. (And what I mean by “working”that is that you are back to achieving your full function without the need for regular expensive treatment strategies that only appear short lived).
If not, then I hope this discussion begins to sow the seed of doubt that maybe there is an alternative way of thinking about this condition that gives the keys of control back to the patient and enables a return to function.
If there is even a seed of doubt, I would suggest readers take a look at this evidence based you tube clip that underpins a lot of the reasoning that I have discussed:
https://m.youtube.com/watch?v=RbSF3-_b7bI
And please, let’s keep any future comments positive and non derogatory on all levels. Otherwise, pertinent issues get lost in emotion.
Best wishes
Helen

Helen,
I think many well-educated SIJD patients like myself are aligned with you that there is definitely a physiological component to successful pain management. Maybe a layman’s way to explaining it is that HCP’s need to treat the whole patient, rather than simply identifying and treating the source of pain. However, that second video that you provided is exactly the type of dismissive BS that many of us have been fighting against. Some, like myself, for decades.
Trust me, I am no malingerer. The source of my SIJD is a damaged sacrotuberous ligament. My left S/I is definitely mobile. It definitely responds to manipulation. An injection of lidocaine into the joint provides 100% relief (until it wears off of course). My condition is not “in my head” or related to stress in any way. Yet, I have had to work my way through over 20 HCPs until I found one who provided the right mix of manipulation, PT, “Prolotherapy” (yes, it really works for me), pain medication, and general support, to allow me to keep working and not become bedridden. You have no idea how many doctors have told me that “it’s all in my head” or insinuating that I’m just trying to score narcotics.
I completely understand that there is no cure for my condition. I have met with the chief surgeons at both Georgetown and Johns Hopkins who have advised me to “try everything” before I resort to fusion, to include Prolotherapy, and that’s the attitude that keeps me moving forward. I’m not stuck in a belief system. I’m fighting a medical establishment that refuses to acknowledge S/I mobility as a possible diagnosis for my pain and nerve symptoms.

Wow, again. I don’t think I have ever replied twice to an AdamMeakins blog. It is kind of sad and hilarious all at once. In no particular order, I think a lot of the angry replies are from people who don’t yet understand pain science,as people should understand, pain is an output, not an input from the periphery. Second, what is a diagnosis of SIJ pain? Just because it hurts there?? I don’t get that. Following on from that if you have a “diagnosis” of SIJ, why is it so hard to fix then if we “know” what is wrong. Thirdly, from some of the respondents who claim a one off manoeuvre of their SIJ ruined their lives, well that is a can of worms. Firstly, pain is pain, if you have it, experience it, well you do. But rationally you have to look a bit deeper in those circumstances. The human body is a very strong structure that moves and twists ,lifts etc everyday. How would a controlled biomechanical stretch ruin someone? (assuming it wasn’t an aggressive manipulation).
Finally, I think we need to call bullshit when we see it in manual therapy. We may never get rid of it ,but we must reduce it.

A round table discussion came out with the following;
The SIJ does not pop in/out
There is very very minimal movement in the SIJ
There is SIJD, quite rare but there are antagonistic tests
A fit and healthy individual would not normally suffer from SIJD, no previous history etc
‘…….. strengthening program’ that’s the way forward
Referencing wikipedia! Peer reviewed?
A year of treatment of any sort should be reviewed as to if this is the right treatment
Read the article for what it is and not what you want it to say/not say

It is sad to see that there is still such a huge divide between pain science and the biomedical model. It is even more upsetting to have real pioneers of pain science like Peter o’sullivan misunderstood completely. He did not imply that patients with pelvic girdle pain are malingerers, there was genuine concern in his voice about individuals being misinformed by health professionals. His research along with a number of respected researchers (Butler, Moseley, Flor and many others) have shown the strong effect the nervous system has in protecting ourselves when we suffer with long term pain. Chronic pain is not simple it is extremely complex which is exactly the reason why when an individual suffers from long term pain (whatever the body part) we want answers. I wish that treating chronic pain with an injection and a manipulation was that simple but it really is not. Pain is a multi sensory experience influenced by a multitude of factors that is ultimately controlled by the brain. It is a subconscious system that looks to protect us from harm. It becomes a self perpetuating cycle like any feedback mechanism that the brain controls subconsciously. Our body systems adapt to stimuli and learnt behaviours. I.e your muscles becoming stronger with gradual increase in load.
It’s an adaptation of our nervous system that becomes better and better at being able to recognise what can be a driver of an individual’s pain. In this case pelvic girdle pain.
I realise this is completely off topic (tigers sacrum popping out) but it seems that there is an underlying cause to some of the comments being made here. Adam I am disappointed that some comments have missed the point of your blog completely and that you have been chastised. It does highlight that in some rare cases that the biomedical model is still as strong as ever.

It is sad to see that there is still such a divide between pain science and tissue based pain. It is also a shame to see that Peter O’Sullivan is so misunderstood. If you actually listen to his blog there was no suggestion of malingering. There was genuine concern in his voice regarding individuals suffering from pelvic girdle pain.
Pain is not simple you cannot use something like touching the area that is painful as a predictor of outcome, this is an extremely naive and somewhat damaging approach. Pain is extremely complex influenced by a multitude of factors. Pain does not exist in your tissues. It is not your tissue telling you you are in pain, your brain does this. Just like your ears don’t tell you you are listening to your favourite song on the radio. Your brain does this. Your nervous system “put simply” is the delivery system. Your senses exist all round your body and it is your nervous system (like any other system) with training that gets better and better and being able to recognise the stimuli it is subjected too. This has nothing to do with the premise of it all being in your head, except for the fact that your brain is in your head……
It is a shame that there are individuals still out there being misinformed and still holding onto a strong desire to want people/HCPs to understand their story of the suffering they went through. There is so much strong evidence out there by researchers that are paving the way to understanding the complexities of pain (Butler, Moseley, Flor and many more) and have have shown that what you experience in terms of pain is not equal to the level of tissue damage you suspect their to be. Chronic pain is complex and debilitating hence why something like chronic SIJ pain (and any other body part) can be so frustrating and the desire to seek treatment is so strong. However having injections and multiple manipulations is not an effective way to continue to manage your symptoms due to some of the long term side effects that these forms of therapy can have.
I realise that this is getting off topic (which was medical professionals rightly or wrongly using incorrect terminology to describe what potentially happened to Tiger’s Sacrum) but it clearly also created a strong message from Adam about his beliefs and evidence based understanding of the SIJ. It also created a strong response with some clear comments about how angry and let down some individuals are by the healthcare system, however this is not a reason to chastise one healthcare professional over another.
I only hope that we have more discussions like this in order to educate individuals that have commented so strongly about their experiences with chronic pain (SIJ pain) in the hope that pain science can be better understood.
TNP

Well, congrats adam on the blog and all the responses…. Its good to see the emotional reactions too…. People caring for loved ones…. (Attacks a little less, but hey we all do this once in a while…
A few tips on the SIJ… It can be a problem (in a mechanical or tissue based way) in 3 ways:
-rheumatologic conditions
-after childbirth
– post trauma (car crashes, falling of a roof etc etc)
So then we need to consider the SIJ as a direct cause of pain…. (But it still does not pop in or out of place, by all means i do not state there is no mobility in the joint, it would not be called a joint otherwise)
But then again in these conditions we need to think movement, loading or deloading tissues, graded exposure, reassuring the patient they will be fine etc etc
In chronic SIJ pain ( no dysfunction) … The pain is felt in this region, but that does NOT mean there is something WRONG with the joint… In persistant pain there is more to adress than just the region where the pain is felt (emotional state, thoughts about pain, fear, avoidance etc ect… The list goes on….
Wanted just to most a short comment, no reason to personally attack adam, he’s a nice guy with the best intentions for the physio bussiness….

Here is a list of the specializations I have consulted in my two year search for a diagnosis of the injury I suffered two years ago when I found myself in immediate severe pain after lumbar traction by the same, highly experienced physiotherapist who provided me with a copy of “Pain 101” which is a condensed patient version of the theory the Naked physio has provided above: 4 highly experienced and renowned physiotherapists (worldwide) – I’d be happy to provide their names, 2 physiatrists, 2 pain management physicians, 5 orthopedic surgeons, 2 neurosurgeons, 1 neurologist, 1 psychologist, 1 prolotherapy physician. There are probably more. The unanimous diagnosis is sacroiliac joint dysfunction due to ligament injury with secondary piriformis syndrome. What interests me the most about this conversation is that the professional physiotherapists here are quite adamant that a patient with sacroiliac pain must have a condition which is “all in their head” due to a hypersensitized central nervous system and that CBT and exercise is all those lazy, crazy loafers need to recover. The professional physiotherapists here can say this without exception and without ever having laid eyes on any one individual patient in question. Doesn’t that make you think? Personally I believe this must point out some fundamental flaw in the education physiotherapists are getting, in general. And also comments that individuals commenting must be professionals, not patients because they have educated themselves on the condition which they have. Also the assumption that those here arguing that in fact sijd and sacroiliac ligament injuries certainly do exist, know nothing of the theory of pain and are not educated enough themselves to understand what component of their injury or condition can be attributed to mind-body syndrome. Open your minds Physiotherapists! And do your research! As an educated, si joint injured patient, I’ve done my homework. I will take the diagnosis and treatment advice of the international team of healthcare providers I have cobbled together. If it’s all in the patients head, how do you explain the approximately 20,000 sacroiliac fusion surgeries done worldwide with a success rate around 75 percent? Sacroiliac and pelvic injuries are complex and there is no one size fits all. That makes it challenging and seemingly perplexing for the majority of physiotherapists. There are experts world-wide, such as Diane Lee in Vancouver, Canada and others in the US and Europe who offer courses for PTs should you wish to expand your knowledge!
Note to Adam: are you sure those Youtube videos posted above meet your criteria? You may wish to remove those links.

As Physiotherapists you have completed a degree which is simply a foundation by which you can further expand your knowledge through clinical, hands on experience and through post graduate learning, which all physiotherapists should undertake continuously as healthcare providers. A Physiotherapist degree does NOT make you all knowing – you are not doctors, you do not have all the answers. Admit it. The pelvis is complex and no two injuries or conditions are the same. The sacroiliac joint is THE major weight bearing complex in the body transferring weight and force to the lower extremities. As such it is 1) almost impossible to immobilize and 2) ligaments have low blood flow making them prone to slow and imperfect healing or non healing. How you can attempt to ascribe one theory of pain to such a complex area and all patients where no two injuries are the same and to an area which has confounded physiotherapists, physicians, scientists for decades – now that’s hilarious. You must be quite a brilliant lot of people.

Patti,
You are correct, a Physiotherapist degree does NOT make you all knowing (although I’m confident Adam never said it did!), physiotherapists are not doctors, true, they don’t have all the answers but neither do doctors.
Yes, the pelvis is complex (isn’t the whole body?) and certainly, as you say, no two injuries or conditions are the same. Actually, let’s just say no two people are the same….remember we are dealing with people here, who, like you, happen to have a painful problem and a very active nervous system.
Sincerely, I am very sorry to hear of your suffering and I’m sure you needed a diagnosis; however, it seems to me, labelling your pain problem a ‘dysfunction’ or a ‘syndrome’ is a cop-out.
Without moving into another commentary on pain science….there are many excellent blogs reviewing that information….I would just like to ask you Patti, how does an SI joint signal pain? How does it become ‘dysfunctional’ despite being such a tough “weight bearing structure” and what is ‘pyriformis syndrome’ when a syndrome is a collection of symptoms (poor pyriformis, why does a single muscle get so much blame despite the fact that muscles can’t actually signal anything, only nervous tissue)?
As a well-informed health professional (albeit lacking the courtesy title of Doctor), with access to exactly the same research and information as physicians, physiatrists and neurologists, I have to agree with Adam and others who have commented positively in response to this blog post.
Yes, there are occasionally very painful issues associated to the SI joint but unfortunately, as with many other painful conditions, medical professionals often contribute to the development of a problem through POOR DIAGNOSIS AND CLINICAL REASONING, often leading to inappropriate (failed) interventions and the resulting problem of persistent pain.
I wish you luck in finding a solution, be wary of self-proclaimed ‘experts’, they may not be expert critical thinkers.

Hi Adam,
Thanks for another successful blog post. Its always interesting to see great divide between schools of thought such as SIJ pain. Simply put, the thought of something moving out of place or not being aligned needs to go. It not only misinforms the patient, but instills fear-avoidance behaviors, and makes them more dependent on health care practitioners to “fix” them. There is lots of evidence to suggest decreased self-efficacy/coping skills leads to greater disability and more reliance on health care. There is always something that the patient, like Tiger, should know what to do (i.e lumbar AROM ex’s) in case of a flare-up. This should be provided by his medical staff a some point…? Moral of the story, it is unfortunate that a large community is still reinforcing the idea that things are out of place 🙁
Based on the anatomy (thick ligaments, form/forced closure), many excellent papers from Laslett et al, and clinical experience, I feel confident that true SIJ pain is most likely not the culprit for posterior lumbo-pelvic pain when there is no history of direct trauma. There is no doubt that the SIJ can get ‘grumpy’ or ‘angry’ like any joint/tissue, but low back pain often the culprit.
In Tiger’s case, we know there is history of low back pain, along with a recent back surgery (not SIJ fusion). Additionally, like many injuries, there can be future episodes of low back pain, likely due to some irritated muscles or nerves. To settle this down, a manipulation may due to the trick, and if Tiger was better informed, he would have stated that the technique helped relax/reset the muscles similar to hitting “control, alt, delete” on your computer. This thought puts a better picture in our mind and is more informed. However, the thought that the sacrum broke free from its anatomy, displacing, and falling onto nerve, and then pushed back into place with a manipulation is simply untrue.
In order to form a proper discussion we need to accept the evidence along with expert opinion and maybe add some anecdotes. Unfortunately for SIJ subluxation, a key piece is missing, the evidence. I am sure there are several anecdotes that may feel like the SIJ “came out” and were somehow reassured that it did, but frankly, it probably did not. Of course you can never say “never”, but with the knowledge we have today, Tiger Woods and the other 80-90% of earth inhabitants, we are likely experiencing low back pain.
Great Blog,
Sean

It shouldn’t come as a big surprise that patients who are convinced that the pain they experience in the SIJ region (or any body part) is driven by a discrete mechanical dysfunction, only manage to find any relief from a treatment they are convinced can ameliorate said dysfunction. And it shouldnt be surprising that following any resolution of pain from such treatment, patients will emotionally and defensively defend said treatment until the cows come home. This is not the patients’ fault. Its an indictment on the (at best) incomplete or (at worst) erroneous explanatory narratives such patients have received from various practitioners, who themselves peddle treatment methods that lack a defensible theoretical framework that considers and accounts for variables that we know influence a persistent pain state. Any resolution of pain that follows treatment that claims to realign/stabilize/mobilize/put back in the SIJ should not necessarily be assumed to be entirely the result of reduced nociception secondary to manually (or surgically) driven mechanical changes to structures within the SIJ. Of course there are structures within and around the SIJ that can be strained to the point that nociceptive pathways are activated… but to assume that that nociception is the primary driver of any long term persistent pain problem of the pelvic regions is to ignore what is known about the neurophysiology of pain.
Consider the following example. man trips and falls onto the point of his knee. SIJ has to contend with significant shearing force in A-P, inf-sup direction. Lets assume no other structures in the body are strained (for the purpose of this example). Man present to physio with all the signs of an “upslip”. Physio explains that the force of the crash probably strained the ligaments around the SIJ, but in all likelihood, the joint itself is not “out of place”. Its more likely that
– the nociception from the strained tissues set up defensive motor output to the muscles around the pelvis and hip
– the strained tissue released some chemicals that trigger an inflammatory response
– inflammatory chemicals excite the nociceptors in the area
– the defensive motor output, sustains strain on tissues, perpetutating a nociceptive drive
– the defensive motor output can sustain the SIJ in a fixed position
– the nociceptive drive excites other neurons in the dorsal horn, thus amplifying nociceptive signaling to the CNS
– your cognitions, understanding, fears, anxiety of affect the “meaning that is attached to this nociceptive input, which influences the extent to which it is felt as pain.
It is most likely that following a week or so of NSAIDs to help with the inflammatory drivers, and some rest to allow the strained tissues to heal, we will be able to start to apply treatment that will help to reverse all of these defensive mechanisms (defensive motor output, peripheral and central sensitization). These defensive mechanisms are normal… we just dont need them to hang around any longer than is necessary. Long term pelvic pain problems tend to be more about the persistence of these defensive mechanisms even though the problem itself (the strained SIJ joint/ligaments have healed). The ongoing defensive motor output that persists in the form of a positive feedback loop with the sensitization of nociceptive pathways, is likely the driver of any observed asymmetries in joint motion/position at the SIJ. The treatment that will help your body to shift out of “protection mode” doesn’t have to be directed at the SIJ itself, although it may help. The key is to understand that your pain and stiffness is the first step towards its resolution. Treatment that desensitizes your nociceptive pathways, and reduces defensive motor output, will allow your SIJ, and the rest of your body to move normally again. For some people it takes only days or weeks to get back to normal, for others it can be months. There shouldnt be need for surgery (although there could a need where there is large trauma/force involved), and the treatment approaches that are hyperfocused on doing something mechanically and directly and manually to the SIJ are superfluous to the extent that those doing them ignore, or are ignorant of the extent to which other elements of the clinical interaction might be driving any observed outcomes.
The message is simple for patients… your pelvic pain is not a manifestation of structural defect/dysfunction… it is at least in part a manifestation of defensive neurophysiological processing. Its up to your physio to guess at the relative proportions of “defense”vs “defect” for your individual SIJ pain problem.
if your physio has not heard of any of the stuff I’ve just written about, or is in the habit of leaning more towards “defect” than “defense” with regards to diagnosis, i think you should find a new physio.

As always, another excellent blog exploring the myths surrounding so many issues experienced by patients. The comments sections always make for interesting reading – really provides an insight into the beliefs of patients regarding pain, especially in such an emotive area as the spine. Undoubtedly many people around the globe have had persistent problems with back/hip pain, pain which perhaps is made worse with harmful behaviours/cognitions reinforced by clinicians who themselves rely on outdated or poorly evidenced scientific theory to explain and treat it.
In my own clinical experience, albeit fairly limited thus far, a large proportion of patients who present with lower back or sij type symptoms describe their own issues along the lines of ‘popped out’ or ‘misaligned’. As we know, this simply cannot happen from a structural point of view due to strong compressive force of the ligaments and muscular structures in these areas. Not without significant trauma or underlying systemic disease at any rate.
I wonder if these beliefs will continue to persist within society, and for how long. Surely as our profession places a greater emphasis on scientific understanding and validity, we will start to see this being eroded from a patients vocabulary? I suppose however that people seek help and advice from a range of clinicians (not solely physio but chiro, osteopaths, sports therapists etc whose education or working practices I can’t comment on) , who may or may not continue to propagate this type of language.
This article, and the comments section, really underlines the importance of the educational aspect of our job – to educate patients in how the body can be injured, and how pain works even at a basic level will hopefully sow the seeds initially for a more successful outcome further down the line, not just for that patient but everyone who they will subsequently talk to about their experiences.
As always, great reading and some thought provoking moments. I always come away from your blog feeling that I have learned something new so thanks for that Adam!

It is nauseating to hear you all congratulating each other. This is all an intellectual exercise for you. You had an opportunity here to learn from people who are experiencing the condition, but you are too set in YOUR beliefs to learn something new. The founder of the SIJD foundation in the U.S. was a college athlete who was injured doing a swimming flip turn. She struggled for many years and finally had a screw fixation surgery that gave her her life back. Now she is trying to get the word out to patients who are looking for answers and to clinicians who don’t understand the condition. What it will take for you to understand this is for you or a loved one to have this happen. That will completely change your perspective. Then you can go through the experience of having so-called professionals tell you your injury is IMPOSSIBLE.

Bisco, I don’t disagree with anything you’ve said. In some cases this is correct. In others the evidence is starting to build, that if you remove the joint hyper-mobility, the lower extremities muscle dysfunction, imbalance and neuromuscular problems cease to exist.
Based on my personal experience, for me having a diagnosis of sijd and secondary Piriformis syndrome (hip rotators problem) is important as it rules out the lumbar spine as the primary pain generator and directs the physiotherapy regimen which is quite different than the physiotherapy regimen of a disc or facet patient. Trial and error, three years of constant research and consultation with every expert in the field tells me this. Dr. Stuart McGill is another expert worth investigating.
In regard to Tiger Woods:
– level of fitness is not a good indicator of who is at risk to develop sij problems. I know a military special forces trainee who became disabled by sijd.
– Tiger Woods has a profession in which he is continuously doing the same repetitive motion. This puts him at risk.
In regard to the psycho-social aspects of chronic pain, a great book that all patients should read before considering surgery is entitled “Back in Control”.

Sacroiliac joint dysfunction does not equal spinal pain!

hi patti, can you provide me with the cases where the removal of hypermobility of the SIJ results in the ceasing of muscular dysfunction, imbalance and neuromuscular problems? For your claim to hold water researchers need to demonstrate the following:
1. that we know of a way to reliably assess for and identify hypermobility of the SIJ
2. if SIJ hypermobility is reliably identifiable, that we can reliably attribute pain in the SIJ region, in a causal manner to this hypermobility
3. that removal of this hypermobility (presumably by surgical fusion or stability exercises- multifidus/TA, deep hip mm etc) is measurable
4. that the removal of hypermobility via said interventions (above) affects “muscular dysfunction” or “neuromuscular problems” in such a way that pain is reduced or eliminated.
note: i’m assuming that what you refer to as “muscular dysfunction” and “neuromuscular problems” = what i referred to as “defensive motor output”?
Can you demonstrate any of these points?
If we agree that defensive motor output is a primary driver of symptoms, wouldn’t it make sense to direct treatment towards those interventions that best stand the chance of reducing such defensive motor output? What factors might lead to the persistence of defensive motor output at the SIJ? Dont you think its possible that when a physio tells a patient that his SIJ is hypermobile/unstable, that this might plant some unhelpful cognitions with regards to the patient’s own opinion about the durability, tolerance to loading of the SIJ and influence (non consciously or consciously) their confidence and approach to occupational, recreational and sporting movement? What then might help reduce defensive motor output and sensitization? Is it necessary to move the SIJ itself in order to achieve this end? I dont think it’s necessary, but it does seem to help to provide non threatening sensory input from the SIJ region.
Why would i, as a physio, hang my hat on a “the pain you have in the region of your SIJ is the result of hypermobility of the SIJ” explanatory narrative?? I’d have to be able to answer points 1-4 above first, which i cant do ( no one can). And I’d also have to account for other variables that arent accounted for in such a narrative.
None of this is to suggest that an unstable SIJ is never a primary nociceptive contributor to the CNS’s assessment of threat state and projection of pain to the SIJ region… but its not fair on the patient for me to provide such a narrowly framed explanatory narrative. Pain is never that simple, its always multifactorial and its a shame that even with all his money tiger hasn’t been exposed to a balanced and reasonable explanatory narrative for his pain. I also think its a shame that you appear to have been exposed to, and now adhere to a similarly narrowly framed explanation for your symptoms and any relief you have gained.

I’d just like to add that when I say pain is always multi-factorial, I don’t want that to be interpreted as me saying “pain is all in your head”. All It means is that pain is ALWAYS more complex than a linearly arranged sequence of thermo/mechano/chemo-reception>>>>> afferent flow along nerves>>>> pain… so we owe it to patients to ALWAYS provide them with information that is inclusive of this complexity. Much of the language used to categorize clinical presentations of pain have connotations attached that deny the patient an understanding of the complexity of their pain problem. This denial could be insignificant for an individual patient who responds well to whatever treatment they receive for whatever specific, narrowly framed diagnosis they have received. But such a denial can be a disaster for the non responding patient, who then begins a trial and error journey across multiple professionals, each one lumping a different narrowly framed diagnostic label, with a concomitant treatment plan. And the multitude of various diagnostic labels and treatment regimes that exist out there simply add to the overall confusion and misinformation with regards to persistent pain problems at a societal level, thus perpetuating a cyclical generation of erroneous cultural ideas about pain, why it exists, what it means, and how it might be treated without having to become a “patient”, or have surgery, or blow $1000s on conservative treatment regimes that a conceptually blinkered..

Patti, the term “SIJ dysfunction”, as distinct from “SIJ or low back pain” also requires some deconstructing. The concept of mechanical dysfunction distinct from pain is popular with followers of diane lee’s paradigm for treating pelvic pain. The aberrant mechanics are argued to arise either from trauma, or insidiously from inherent or lifestyle acquired flaws in the motor control system’s capacity to provide optimal joint compression for tasks of every day living. The idea being that an optimally firing motor control system will always provide just the right amount of joint compression at the SIJ (or any joint) to match the load requirements of any given task the body is performing. If the motor control system is not providing optimal stability for daily activities, the SIJ is said to be dysfunctional… even though it might not be painful.
I think there is merit to the idea that there exists an optimal degree of joint compression for various physical tasks… i need more myofascial force to stabilize my lower back and SIJs when I bend to lift 100lbs than when i bend to lift up a pencil. However, the clinical utility of this conceptual framework is limited by our inability to do two things
1. to (for a given individual) measure or even guess at the range of NORMAL compressive forces (generated by muscular force) across an SIJ that effectively facilitate load transfer such that there is no excessive tissue strain or nociception generated from within or nearby the SIJ. If the dysfunction is not related to pain, how does the dysfunction manifest, and how is it identifiable? Is it only detectable via palpatory motion tests that have been shown to be unreliable? I suspect, given the range of symmetry and shape of SIJ joint surfaces across individuals, that the range of NORMAL forces for which there is no significant strain to the tissues in and around the SIJ is greater than the range of forces that the average patient subjects their SIJs to from day to day. Even if we could identify a range of forces outside of which the biomechanics of the pelvis are so affected that tissue strain to the point of nociception begins to arise (we… to point 2)
2. dont tend to see patients who arent experiencing pain. So by the time they see us, we cant rule out the influence of the presence of pain on ongoing cyclical processing of defensive motor output, sensitization and pain. Therefore, there is no way to make judgment about how “dysfunctional” the SIJ is because the degree to which the motor control system that act on the SIJ is behaving “non optimally” as a result of “trauma” or “non traumatically” from lifestyle behaviours cannot be distinguished from the extent to which the motor control system acting across the SIJ is behaving “non optimally” because of the presence of nociception, and the cylical processing of defensive motor output, sensitization and pain by the CNS.
So while there probably exists an optimal degree of motor output for optimal joint function (to conserve compression/shear at joints surfaces)… it exists as a moving target, that varies from moment to moment as the demands of a physical task shift from moment to moment. Its not something we can hope to parcel up in a neat package of clinical tests with a view to making discrete diagnoses such as SIJD. As I said, the neurophysiology accompanying these biomechanical issues is simply too relevant and complex to leave out of the explanatory narrative.
We need to provide info that accounts for those variables that we know have an influence on our clinical outcomes. A narrowly framed diagnosis that considers the problem to be centred around “dysfunctional mechanics” without being inclusive of the full range of factors that can affect said mechanics is inadequate.

Here is a pertinent review of the literature on this subject: http://www.pain-ed.com/blog/2014/05/02/my-pelvis-is-hypermobile-and-goes-out-of-place-really/

Excellent, excellent blog as usual Adam. Please don’t let the ad hominem attacks stop you from continuing to push evidence/ science based medicine. You are doing a great job. Keep it up

Hi Adam,
excellent blog, i’ve just started to follow your opinions, ideas, clinical and scientifical knowledge. I totally agree you with Tigers problem. Pain is coming from the lumbar spine, and my opinion for manual therapy (SIJ or any joint, soft tissue etc…) is that if you just touch patients, it leads pain decreasing due to several hormonal and neurophysiological effects. But how long this will last?? You can create optimal surroundings for tissue healing process with manual therapy but main question is: How patient can avoid recurrency? My answer for this is well planned exercise therapy, which sould include always after manual therapy (if MT is even needed…).