The Truth About The SI Joint That You Shouldn’t Ignore

Early on in my career, I’d have people come in with hip pain and like it was a script, I had an explanation ready.

I had a couple of go-to orthopedic tests, (Gillet’s, Standing Flexion, and Supine To Sit) and I’d boast about how their Ilium was rotated to their Sacrum. This, of course, resulted in a leg length discrepancy and had to be the source of their pain!

I’d do a muscle energy technique that would cause a loud “pop” from their pubic symphysis and this look of relief would wash over the patient’s face as if I had just done some sort of magical repair.

But, as time goes on not only have I started to realize that most of the above concepts were wrong, I was SUPER wrong for believing I was doing some magical repair (I’d like to think my ego has shrunk since then).

So, the question begs, what’s really going on with this darn S.I joint!?

Well…here’s what I’ve found out.

Rotation Of The Ilium

Whenever we talk bout the ilium rotating we are discussing nutation and counternutation.

Nutation is when the sacrum is moving in anterior/inferior…think to nod your head. The interosseous sacroiliac ligament (which is one of the strongest in the body) connects the sacrum and the ilium and prevents this movement from happening.

Counternutation is the opposite, moving in posterior/superior…think looking up at the ceiling. The posterior sacroiliac ligament connects the PSIS and the iliac crest with the sacrum and also prevents counternutation.

This is essentially what we were told to test in college and it was all about how the ilium rotated on the sacrum. So, we have to ask the question, how much rotation can there be?

The degree of movement is typically measured through the axis of rotation occurring through the second sacral vertebrae so the sacrum is performing its nutation or counternutation in the sagittal plane (the body in half from head to toe). The amount of movement is thought to be anywhere between 15° and less than 3°.

There is even discrepancy as to the direction of movements as one study showed that when a patient is forward flexing (like we do for some of the SI special tests) the sacrum was just as likely to nutate as it was to counternutate.

However, there are extenuating circumstances that would allow more movement in the joint such as those who have S.I. Joint disorders (which we will get into later), but when we look at healthy individuals who are perhaps experiencing some pain in the area we see much different numbers. One study actually showed in healthy individuals the average total rotation was only around 2°. They even examined 25 patients with sacroiliac joint syndrome and found the movement range to only be 1-3° with no difference between the symptomatic and asymptomatic side.

When we look at a goniometer or a protractor to see what 1-3° looks like, it’s pretty minimal and I dare say REALLY difficult to see with the naked eye.

So, we have to ask the question, are the aforementioned orthopedic tests accurate or valuable for us to use?

Well, a systematic review showed the use of Gillett’s test to evaluate movement of the SIJ to have a 47% intertester reliability, which shows this test to be unreliable. Because the movements are so limited and minute it is even suggested the movement would be impossible to see. 

Even if we’re doing tests to look for some sort of dysfunction, another review showed the most typical tests used were: Faber, distraction/compression test, focal SIJ tenderness, seated and standing Gillett’s, femoral shear, and modified Gaenslen’s were not reliable to show the likelihood of SIJ tenderness unless three or more of those provocation tests were positive, the pain was unilateral, the pain is below L5 without lumbar pain, or if pain increases with rising from sitting. 

Now that’s a lot to take into account especially if there is no history to suggest any kind of a pain or dysfunction disorder.

Of course, some of our patients will be referred for imaging, but even that isn’t helpful in the evaluation of SIJ pain unless looking for tumors, infection, or fracture, but hopefully, you’ve ruled some of this out with your intake by ruling out red flags.

What Should We Be Looking For?

If we look at a broader term, pain around the SIJ can be referred to as Pelvic Girdle Pain Disorders (PGP).

Specifically, when we look at this, the cause is around pregnancy, trauma, arthritis, and/or osteoarthritis, but excludes things like gynecological and urological disorders.

Pregnancy is one of the factors that we know can influence women to experience PGP as the effect of hormones (higher serum levels of relaxin and progesterone) affects the ligaments in the pelvis to increase their laxity, and possibly influences stability of the pelvis, but more research is needed to clarify how the role of hormones may differ in various presentations. However, this decreased joint stability can be compensated for by a change in muscle function. There is also evidence to show some of the risk factors associated with developing PGP during pregnancy is a previous history of low back pain and previous trauma to the pelvis.

When it comes to specific pathological issues like inflammatory arthritis, sacroiliitis, fractures, or infections there’s really not much we can do as therapists as manual therapy can’t address the underlying pain mechanism of the disorder, so, much of what we are doing is most likely helping with symptoms as opposed to rectifying the cause. 

Beyond these specific pathological issues there is another group of issues classified as Non-specific pelvic girdle pain disorders:

  • Non-specific inflammatory pelvic girdle pain disorder
    • constant, disabling, non-remitting pain in SIJ, provoked with weight-bearing, pelvic compression, and SIJ provocation tests.
  • Peripherally mediated (mechanically induced) pelvic girdle pain
    • Localized pain to SIJ that in intermittent and provoked and relieved by specific postures and activities due to directional loads and weight-bearing.
    • Usually, they have a clear mechanism or time of onset due to repeated strain or direct trauma.
  • Reduced Force Closure
    • Associated with excessive strain to the SIJ coupled with motor control deficits of muscles that do force closure of the joints (pelvic floor, transverse abdominus, lumbar multifidus, iliopsoas, gluts).
    • Common with postpartum PGP and a positive ASLR (active straight leg raise) test.
    • Functional impairment associated with, sitting, standing, walking, or activities that induce rotational pelvic strain coupled with spine or hip loading activities like cycling, or rowing.
  • Excessive Force Closure
    • Localized pain to SIJ and surrounding tissues, along with positive pain provocation tests.
    • Result of excessive, abnormal, and sustained loading of sensitized SIJ
    • Negative ASLR
    • Compression and local muscle activation (pelvic floor, transverse abdominal wall, back muscles, glutes, iliopsoas) is provocative.
    • Commonly associated with the belief the pelvis is ‘unstable’ or ‘displaced’ but exercise, massage (although I wouldn’t recommend this for the pelvic floor as massage in this area is out of our scope), stretching helpful for pain relief.
  • Psychological influences on peripherally mediated pelvic girdle pain
    • May be associated with underlying stress and anxiety.
    • It can be associated with faulty beliefs, and passive coping strategies, so we have to promote accurate beliefs, relaxation, and active coping strategies.
    • If associated with positive beliefs, and active coping strategies, then focus can be on physical impairments and work on helping with pain control.
  • Central nervous system driven pelvic girdle pain disorders
    • Associated with widespread, severe, and constant pain that is non-mechanical.
    • High levels of physical impairment, social impact, and abnormal pain behaviours.
    • Dominant psychosocial factors (catastrophizing, fear, anxiety, depression, history of sexual abuse).
    • Requires a multidisciplinary approach with medical and psychological management.
  • Genetics
    • People with PGP are more likely to have a mother or sister affected.
    • Possibly a social influence here as well.

While this may seem like a lot to take in, it actually simplifies things for us.

If there is no history of pregnancy, trauma, or inflammatory issues (which we should be able to rule out fairly quickly in our intake process), then we can look at psychosocial factors influencing their pain. 

Now, I know where many are going with this…we can’t treat psychosocial (or many arguing it’s not in our scope).

Well, maybe we can’t treat it directly (okay for sure we can’t, refer out to a mental health professional for that) but we can recognize their influence and work on our treatment and communication from there. Many of these conditions revolve around beliefs, stress, anxiety, catastrophizing, depression, fears, and social impact. We can most certainly address these things by giving some proper education around what they are experiencing. Explaining to them, their hip isn’t ‘out’, their ilium isn’t rotated, they don’t have an inflammatory disease, and pain is normal. Giving them relaxation techniques, helping with symptom modification, and coping strategies can all have a large impact on helping our patients with SIJ pain. However, more importantly ‘promoting accurate beliefs’, might be one of the most important things we can do. All too often we have patients come in who have been told they’re rotated, out, or misaligned, which puts the responsibility on us to educate and correct those beliefs. Sadly, I used to be one of the practitioners telling them this. If I could go back and apologize to them I would, but many of those people I don’t see in my practice anymore. While I can hope this is because I helped and they’re doing better (and I probably did with some of them), I hope that whoever they are seeing now isn’t reinforcing those old narratives, but is giving them more accurate information. I know the way I treat SIJ now, is different than the way I did 10 years ago and now that you have this information, I hope it changes the way you do because updating our narrative is part of our responsibility as healthcare professionals. 

Articles Of The Week December 8, 2019

 

Resilient is one of my favourite words and it’s something we should be working to instill in all of our patients. However, what about when we need to be resilient ourselves? This article gives some great tips and advice on how we can become emotionally resilient.

“How To Become Emotionally Resilient” – Marta Brzosko

You know how much we love pain science around here and the group over at modern pain care do too. Fortunately, they’re willing to share their knowledge and this even comes with a downloadable PDF so you can keep it handy in your clinic.

“10 Steps To “Pain Sciencing” With Success” – Modern Pain Care

Athletes love their ice baths and quite often take them because they see images of their sports heroes doing it as well. However, this may not be as beneficial as we used to believe and may even be hindering muscle growth.

“Cold Water Immersion Cools Muscle Growth” – Alicia Filley

It’s no secret that our healthcare systems need to change it’s the approach to pain management and how patients respond to pain. We need a push to get away from opioids and use more conservative care using education and multidisciplinary care, so it’s great to see major media outlets publishing articles like this one.

“Our Dangerous Fear Of Pain” – James D. Hudson

This is a great infographic to dispel the myth of knees over your toes in a lunge or a squat is a bad thing.

“You’re Over The Line” – Physio Praxis

 

Pain Education – What Might Make It More Effective

 

Pain education is a valuable tool for some, but certainly not all, patients. It can help to provide a narrative or explanation for problems that may remain unexplained by ‘traditional’ medicine or therapy.

This paper HERE regarding chronic lower back pain explores what people are looking for from a visit to a therapist.

more than 90% of patients expected a physical examination, tests or investigations, a diagnosis, reassurance and advice, and clear explanations of causation, symptom management”

How tough is this in many instances with no clear diagnosis or causation available?

Up to 90% of back pain is described as ‘non-specific’ for this very reason. We know that uncertainty is a big deal for many patients. Mishel first proposed this in the “theory of uncertainty of illness” HERE.

Carroll’s paper HERE How Well Do You Expect to Recover, and What Does Recovery Mean, Anyway? Qualitative Study of Expectations After a Musculoskeletal Injury” also discusses the process of diagnosis, uncertainty and the subsequent effect on expectations of recovery.

But although data suggests pain education can help it can also be very tough to deliver.

This quote from Louis Gifford sums it up nicely.

“The patient that learned from their pain explaining therapist that their pain didn’t really mean anything, who suddenly got out of the chair, went home and went riding their bike for the first time in 5 years…just doesn’t really exist!”

SO HOW CAN WE IMPROVE THE DELIVERY OF PAIN EDUCATION?

A question I often ponder is have we replaced anatomy with neurobiology? Do we now bombard people with complex processes involving brains, nerves, and receptors rather than complex biomechanical stories? How much neurobiology or neuroscience is actually required?

In some cases certainly it will be useful, but in many cases maybe it could actually hinder. This does not mean that some of the key concepts such as plasticity, sensitization and the brain’s role in pain are not important but maybe the minutia of information that can be focused on is unnecessary.

Perhaps we can apply some of the information in this paper HERE. Simplifying MRI reports appears to have a positive effect on how they are received. This may also apply to the delivery of pain education. What does nociception or Ion channel mean to a patient? It could end up very similar to VOMIT (Victims of Medical Imaging Technology) HERE if poorly delivered.

Should the focus now be on the delivery and context of information rather than the information itself?

CONTRIBUTIONS

I thought it might be nice to get some other opinions on some of the key elements that go into making successful pain education and reached out to colleagues from around the world, using social media, to pitch in.

Some of the key components I already advocate, but I must admit some others I had not considered and provide valuable food for thought for myself and perhaps also the wider therapeutic community.

I was pleasantly surprised by the elements discussed, almost none related to the actual information itself but instead on the delivery and thought process involved.

Here they are

Slide1

LISTENING

The most consistent point made by the contributors as a whole was listening.

Listening is a key clinical tool. Although pain education is often thought of as the delivery of information, it should start with listening. I think this is advocated on many fronts but as we know patients can often be interrupted pretty quickly HERE and this is always worth keeping in mind.

The desire to be listened to also appears to be valued from a patient perspective and helps to build therapeutic alliance HERE. This is probably vital for those receiving and processing the information. delivered.

This is a good paper on ‘listening as therapy’ HERE

VALIDATION

A couple of patients also contributed to the discussion and they felt that someone listening to and validating their experiences was a big part of their recovery. This also ties into the paper above regarding a patient’s perspective. If symptoms cannot be ‘medically’ explained or solved by traditional interventions, then patients may feel that they are being seen to ‘make it up’ or exaggerate their painful experience. All pain is real and although it can often be hard to describe it is also exactly the way that someone says it is. It cannot be anything else!

INDIVIDUALISATION

Another of the key points consistently put forward was about individualizing the delivery and placing into a relevant context. Now I personally have a bias for placing pain education in context with someone’s current situation. By weaving it into their story and using their painful examples to tie in some of the key concepts I think we are more likely to get some elements of comprehension.

This fits well with the key component of listening. Without listening we cannot place the information in the context of the patient’s narrative.

The question is, is this more effective than information generically delivered? I just don’t know. I think this would be an interesting comparison to study.

ASKING!

One thing I must admit to NOT asking was simply “do you want to know more about pain?” This was brought up by a number of people. This may avoid the very real problem of ramming pain science where it is not wanted. Pain science should be judiciously applied where it is needed AND wanted rather than a therapist dropping knowledge bombs expecting an instant epiphany.

IT IS NOT A PASSIVE EXCHANGE

Remember there are two equal people involved in this. It is not simply a teacher-pupil relationship. Patients lived experiences are also important. The therapist can also learn from the patient, especially when it comes to the patient experiences. Perhaps it should be seen as a journey by two people to find mutual meaning in a negative situation rather than simply an educational experience.

PAIN SCIENCE IS A WAY OF THINKING NOT AN INTERVENTION

One of the criticisms that I have seen recently of the application of pain education is that it is seen as a standalone intervention. So rather than bombarding people with statements or analogies that have been previously heard for explaining pain, the concepts and ideas should affect the way we reason, interact, explain and apply the treatment provided.

EXPERIENCES ARE AS POWERFUL AS TALKING

It’s not just about talking; doing is also a powerful educator. Perhaps sometimes talking is needed before and after the doing, but without the actual doing, we cannot ‘prove’ the point. Beliefs about the body are a good example of this. Without SEEING or FEELING a different, positive outcome to that expected, potentially a number of times, a belief may remain in place.

Again listening is key. What are the key experiences that need to be reconceptualized in a physical sense as well as a cognitive sense?

FIND OUT HOW YOUR EDUCATION HAS BEEN INTERPRETED

As with any part of the therapy process, pain education has the potential to have a NEGATIVE outcome as well as a positive one. We may well baffle people with talk of brains and outputs etc and HOW they interpret this information is the arbiter of success, however well meaning or comprehensive the input by the therapist.

This may boil down to wording, health literacy, and therapeutic alliance. The list of potential influencers is endless, but essentially the ability to mitigate any negative effects could be dependent on simply asking!

We may be able to influence this interpretation by being clear and concise, using bite-sized chunks of information, avoiding confrontation regarding beliefs and also avoiding negative or long-winded medical or anatomical jargon and terms.

REFLECTIVE QUESTIONING

Don’t just provide statements, also use reflective questioning. This may help to facilitate understanding and apply this new information to their own personal experiences and think critically about some of the beliefs they may hold.

Let’s say someone has a negative belief regarding their back because of a slipped disk a number of years ago. We could suggest that structure and symptoms don’t always display a consistent relationship. We could follow this up by asking if their symptoms come and go (as long term back pain generally does) and would this be a sole cause if the ‘slipped’ disc remained a constant.

Of course, this is just some opinion/s but collectively they could be valuable!

KEY POINTS

  • People are looking for answers
  • Uncertainty makes things worse
  • Pain education may provide some explanation
  • It is tough and often fails

SOME THINGS MAY MAKE IT MORE EFFECTIVE

  • Listening
  • Validation
  • Individualisation
  • Asking if it is wanted/needed
  • It is not a passive exchange
  • Pain science is a way of thinking not an intervention
  • Experience is as powerful as talking
  • Find out HOW your education has been interpreted
  • Reflective questioning

Articles Of The Week November 24, 2019

A tale of two nails shows us how thoughts, beliefs, perceptions, emotions, past experiences, context, and input from your body all affect your experience of pain. This also shows us (and our patients) how tissue damage is not an accurate indicator of tissue damage.

What Changes Pain? – Rachel Zoffness PhD

With our ever-growing technology, there is an increasing epidemic of loneliness and isolation in our modern society, which can have a major impact on our social culture. Part of what we can do as therapists is create a safe place for people to experience touch which is sadly lacking in our modern society. And the best part, it doesn’t have to be filled with fancy techniques to be helpful!

“Touch: The Need For Comfort In Times Of Isolation” – Heather Thuesen

For any athlete a warm-up before and a cool down after competition is important. However, the way we have done it for many years may not be the best way, and could even be causing harm. Research has told the Australian ballet that strengthening in end ranges to be more valuable than stretching.

“Why The Australian Ballet Dancers Quit Stretching” – Lara Bianca

I love this post because it preaches simplicity. All too often as therapists, we think some huge detailed exercise prescription is necessary to help a patient. But, you know what will help them more? The exercise they will actually do, and quite frankly…the simpler, the better.

“Less Is More…Some Thoughts On Exercise Prescription” – Mike James

Have you ever felt little nodules around the iliac crest on a patient? Turns out these have a name, and there is a possibility it could contribute to a patient’s pain experience.

“What In The World Are Back Mice” – Whitney Lowe

 

Functional Mobilization To Improve Squats

 

First things first, I used to give credit where credit was due. That was a key part of The Eclectic Approach and Modern Manual Therapy. However, I received cease and desists for using the terminology of Institutes I don’t teach for – it’s not like I’m not giving credit where I originally learned these concepts!

If you or your patient has pain with squatting, try these variations

  • Tibial IR and Femoral ER with closed chain flexion
  • Tibial ER and Femoral IR with closed chain extension (coming up from the squat)

The patient I am talking about in the example (but not the PT I’m demoing on) had a patellar dislocation a few months ago and has been afraid to have his knee go into extension in all closed chain activities. With this Functional Mobilization, I restored threat free knee extension and was able to overpressure it at end range. It was also easy enough for the patient to replicate hourly for his Recovery Plan (what I am now calling the HEP).

Articles Of The Week November 10, 2019

This one hits close to home but is amazing to see. Last year in Canada a junior hockey team was in a severe bus accident that killed some and left others paralyzed. With a new surgery, one of those players who were left paralyzed is actually moving his legs due to an implant that stimulates certain nerves.

“Paralyzed Humboldt Broncos player moves legs after experimental surgery in Thailand” – Joel Dryden

I always find this topic interesting, what does ‘deep tissue massage’ really mean? Another way to look at it is does this really matter? Should we be focusing on the modality or the person?

“Swedish or Deep Tissue Massage: What Do These Terms Really Mean?” – Nick Ng

Have any bad habits? I have about 1000 of them, so I could lend you one if you need it. However, this is probably a better approach, stopping bad habits. Here are nine ways you can stop them.

“How to Stop Bad Habits: 9 Scientifically Proven Methods” – Leon Ho

Here is a curated list of open access case reports on various topics surrounding massage therapy and it’s use. It might save you some time while looking for research.

“Open Access Case Reports For Massage Therapists” – Richard Lebert

As business owners, we are always looking at ways to market our business (even when it’s super busy at the end of the year with people trying to use up their benefits). So here’s something to share…reasons to give and get massage therapy as a gift.

“15 Reasons To Give (and Get) Massage as a Gift” – Raechel Haller