Within the therapy world the assessment and treatment of the Sacroiliac Joint or the 'SIJ' as its more commonly known, can be a fiercely debated area that creates lively, heated arguments and disagreements between therapists, as I recently found out when I posted a comment on Twitter a while ago stating I was surprised that many physios still use SIJ palpation and out dated and unreliable tests to assess this controversial area. After some RSI inducing tweeting, which ended up with one tweeter calling me a ' critical arse' forcing me to write another post here I thought I would write this piece on what my own clinical experience as well as the research and evidence, is telling us how we should best assess a Sacroiliac Joint.
Now for me the SIJ has always been one of those areas I never did like or understand fully, right back from when I was a fresh faced student many years ago. I can recall being in classes having tutors telling me that this joint moves this way and that, and these movements can cause pain and dysfunction, but then I read that acutually the SIJ is inherently stable and doesn't move much at all so?
Then in practical sessions I would have a tutor tell me to press here and there on one of my buddies backsides and say…
“can you feel that counter nutation of the sacrum” or, “do you feel that blocked left sided innominate”
“errr yeah sure'” i'd reply sheepishly with a confused and bemused look on my face,
But if I'm being honest, all I felt was skin and some bony bits and not much moving anywhere at any time! But everyone else seemed to, so like a good little sheep I kept quiet and prodded a few more times and dared not question the absurdity of trying to feel such a subtle movement. Instead I thought I'm just new at this, perhaps I just needed to develop my sense of touch and feel, especially as so many senior physios where telling me that they could feel this and that, so I perservered, and when I qualified every opportunity I got I pressed poked and prodded peoples SIJs, even if it was clear it wasn't an SIJ issue, I just wanted to get better at feeling the movements and doing the tests… I didn't get any better!!!
So I thought I needed more teaching so I went on a very well known SIJ post graduate course hoping this would make me an SIJ assessing machine… It didn't.
Instead I now had to deal with a 'Mr Sacrum' (yep I still got the laminated card) with 6 planes of movement including rotational and twisting movements, bloody out flares, and all types of other shite that I was supposed to be able to detect. I had days of pretending I was a sacrum with my arms up out to the side twisting this way and that, as well as pressing lots more backsides (some nicer than others mind) and again people asking me if I could feel this and that moving, but yet again all I got was skin and bony bits and a sinking despondent feeling as everyone else around me seemed to be feeling things I just couldn't, with shouts of joy ringing out when they felt an anteriorly rotated innominate or gasps when an upslip was found, it was like being back at Uni all over again….
What was going on!!! Was I just a ham fisted numpty that couldnt feel anything???
Well, no actually I wasn't, just being more realistic and some may say cynical in what I could and more importantly could not feel with my hands.
For example, there is good evidence that palpation of the SIJ has been found to be very unreliable and shows poor inter-tester reliability. Holmgren and Waling showed that four common static tests used to detect asymmetry is of “doubtful utility“, and a very interesting study by McGrath questions the ability to detect the commonly used bony landmarks stating “the continued use of manual diagnostic palpation as a basis for manipulative intervention is questionable“. Finally a study by Preece et al highlights the vast anatomical differences that there are in the human pelvis and that variations in pelvic morphology “may significantly influence measures of pelvic tilt and innominate asymmetry“
So it's clear that by just feeling for the SIJs bony bits you are not going to gain any useful information about an SIJ position, just as I've always found.
But what about those claiming they can feel it move or not move!!! Well again I couldn't and still can't, and I do (quite often) question those that say they can, hence my tweet last week getting myself called a “critical arse”.
We know that although the SIJ is a joint and it moves, it doesnt move much, in fact it moves just a few degrees, equalling just a few millimeters of actual movement. Goode et al shows at max its about 8mm of movement, realistically its less than this with average movements being quoted as around 2-3mm.
Three good papers look at the commonly used movement assessment tests used in 'feeling' SIJ movement ie the Stork and Gillet's tests, two from Freburger and Riddle here and here both showing poor inter tester reliability, low sensitivity and poor specificity, and another by Robinson et al confirming the other two studies, so basically telling us that we just cant reliably feel the SIJ move or not.
So combine poor palpation reliability and very small movements and I hope you can see that assessing the SIJ's movement with touch is implausible and delusional, and yet the techniques are still very popular and many claim they can detect these movements, personally I think that this is just therapists desperatly trying to hang onto something they have invested a lot of time and training in, and that gives them a sensation of control over a very uncertain area, even in the face of over whelming evidence and just plain old common sense.
So where does this leave us therapists (and the patients who may also be reading this as well) when we do suspect the SIJ maybe a source of pain (which is very rare in my opinion, but that's for another post) how do we reliably assess it?
Well there are tests we can do, in fact its more a group of tests and it doesn't involve trying to palpate microscopic movements here and there. These tests in combination have been found to be so much more reliable and sensitive in determining IF an SIJ is causing pain rather than trying to determine if its moving too much or too little, or its twisted this way or that, which doesn't really matter if its not causing any pain.
First is just using the location of your pain, Van der Wurf et al showed that you can possibly predict an SIJ issue if the pain is located in whats called the 'Fortin' area but NOT in the 'Tuber' area see below image
However you can't just use the location of the pain alone, we need other tests to confirm the SIJ is an issue. Laslett et al seminal paper along with another by Van der Wurf et al shows that there isnt one stand alone test but rather a combination of 5 tests and if you have a positive sign on 3 or more then there is a 85% sensitivity and 79% specificity for saying the SIJ is the issue.
These tests are
- Gaenslen torque test
- FABER's (Patricks Test)
- Femoral shear test
- ASIS distraction test
- Sacral thrust test
For video demonstrations of these tests check out the this Youtube site with them all on.
I would also add to this list the Active Straight Leg Raise or ASLR test as it has also been found to be validated to highlight pain from the posterior pelvic area here
So in summary I hope you can see that by trying to assess an SIJ by its position and movement or lack there of, or even just its resting location using palpation tests you are barking up the wrong tree and will not gain any useful or relevant information, in fact it can lead you down the wrong road of treatment completely. Just because a SIJ is slightly this way or that compared to a so called 'normal' SIJ (whatever that is) doesn't mean its a source of dysfunction or pain, and that goes for any joint/posture!!!
I would ask that if you are a therapist that still uses palpation test to assess the SIJ to strongly question your reasons for doing this and look at what the evidence is telling us, and STOP. If you are a patient with a suspected SIJ issue and you have a therapist palpate your SIJ claiming they can feel it move or not I would question them why they are doing it or just walk away.
I'm sure this will create some mixed feelings as it did last time I mentioned it, please feel free to comment and discuss the issues I have raised but remember be polite, curtious and respectful, after all I have reflected and feel that actually im not a critical arse… most of the time
Once again thanks for reading