So from this article, many, well ok, one or two people have asked how I treat a painful SIJ if I come across one, so this is the subject of this post. Now again I'm sure this will create some discussion and some controversy, so please feel free to comment and give me your experiences and insights but please keep it personable, for some reason the SIJ seems to get therapists fired up more than any other area, I'm not sure why???
Ok let's go…
The first thing to say again is that I just haven't treated that many painful SIJs so my experience here is limited, I'm not claiming to be a SIJ expert, far from it, it's an area I feel uncomfortable with. However I can confidently say I could count on the fingers of one hand (maybe both) how many I have 'treated' in my career.
I do get lots of patients coming to me saying that they have been told they have an SIJ issue/problem, some have even been told by other therapists that their SIJ is out or alignment or unstable, which is complete rubbish, but when I assess it as described in my earlier post, there is rarely any positive pain responses, its normally something in the lower back generating the pain, and often there is no firm or conclusive structural source of the pain, this is whats call 'non specific low back pain' and it can be frustrating for both the patient wanting a diagnosis to explain why it hurts, and also for the therapist wanting something meaty to give as a diagnosis and to treat, this is why I think the SIJ gets labelled and blamed way too often! Therapists do love to give out meaty impressive sounding diagnosis… Anyway…
A very recent study by Cohen et al 2013 states that the SIJ accounts for between 15-30% of all low back pain! I'd argue this is much less, now this maybe due to my 'normal' clientele being slightly different from the study's. Prevalence studies on SIJ pain seem to show higher levels of SIJ pain are found in less active females and obviously in those during and after pregnancy, as well as those with inflammatory conditions and with elderly arthritic changes.
Ok! So I've found a rare SIJ that is causing pain, what do I do?
Well simply, I get them all doing exercises, great thanks for reading….
WHAT… WAIT is that it??? I don't I poke, prod or manipulate them, don't I give an anterior innominate rotation thrust or a posterior torsion mob here and there….
Well, no I don't, I cannot remember the last SIJ manual treatment I gave, if I do decide to do any prodding, its NOT to change or alter its position and its definatley not to 'loosen' or free it up, let me explain why.
Firstly if we look at the anatomy of the SIJ closely, as in this paper by Vleeming et al 2012 does very well, we can see that the congruity of the bony surfaces combined with the many strong ligaments that cross it make the SIJ a very, very stable joint, it has to be, it transfers lots of load from the legs to the trunk and visa versa, this is termed the SIJs form closure ie its shape and structure.
However, the joint also requires the contraction of muscles around it to help control the small amount of movement that is available to allow effective transfer of stresses across it, this is what's called force closure, read more in this paper from Wingerden et al 2004.
Basically the SIJ wants to be stiff and stable but it also needs to move a tinny tiny little bit occasionally.
Now the two main reasons why the SIJ is thought to cause pain is either due to excessive movement causing shearing forces between the joints articular surfaces, I use the word 'excessive' here with care, as although the SIJ is a joint and it does move, it doesn't move much at all, on average about 2-3 degrees, and about 3-5 millimetres of movement, but it is still thought to be enough to create irritation and wear and arthritic changes.
The other reason its thought to cause pain is that the SIJ becomes stuck or jammed and the little bit of movement that it is supposed to have isn't available and so creates pain.
But are these theories correct!
Now thanks to Greg Lehman an excellent physio and chiropractor and an ex researcher with Stu McGill (he of the papers that have done so much for our understanding in low back pain and stability exercises) Greg has very kindly shown me that actually we can't say excessive shearing, extra movement or laxity at the SIJ causes pain. (Follow Greg here on twitter, and go visit his excellent site here)
This paper here by Damen et al shows that SIJ laxity which is common during and after pregnancy isn't correlated with SIJ pain, they found pregnant women with moderate or severe pelvic pain had the same laxity in the SIJs as pregnant women with no or mild pain, so the so called SIJ laxity isn't the issue
Also the forces need to produce force closure on the SIJ are not very much at all and actually most muscles around the trunk when they activate even gently create enough force to close the SIJ as shown by this study here by Richardson et al So we cannot say that an individual is having SIJ pains as they dont have enough strength to stabilise or force close the SIJ either, if they didn't have enough strength to force close the SIJ they wouldn't have enough strength to stand or sit upright either and wouldn't be in front of you complaining about their pains!
So if not shearing forces or weak muscles causing the SIJ pain, what about it getting stuck or not moving enough?
Well I question if this is even possible, and if it is, how do we know its stuck, and why does it occur? I have already discussed in my other SIJ article that there is no way of palpating or feeling a SIJ move or not move so we can never tell if its stuck. If you haven't realised yet I'm a skeptic and a too stiff SIJ just doesn't make sense to me, the SIJ wants to be stiff and rigid, if its too stiff why would that cause pain? And how on earth does it become jammed or stuck, does something gets inbetween the joint, highly unlikely in my opinion.
So if not due to excessive movement and not due to it being stuck then why does then SIJ cause pain? Well simply I think its just due to overload and excessive stress across the joint that it can't handle and so irritation and nocioceptors around it complain, it's as simple and straight forward as that, no excessive this, no stuck or stiff that.
So how do we treat it?
Simple, as I said earlier, exercises, to build up the SIJ resitance to take an increased load by increasing the soft tissues endurance capacity in and around the SIJ and those that act and influence on it. Which muscles you choose to do will be based on individual pain provocation patterns, fear and skill levels, but in a nut shell I dont think it matters too much, as we know from earlier that all the trunk muscles have a role in producing SIJ force closure, but the muscles of the posterior oblique sling are probably the ones to focus on more, namely the Latissmus Dorsi, Hamstrings, Glutes and of course the large powerful Erector Spinae muscles all of which act on the thoracolumbar fascia.
Image courtesy of saveyourself.ca
How you go about this is up to you, it is obviously guided by the levels of pain the patient is in, if really sore, then non weight bearing strengthening of these muscles can be used to start with until the irritation settles combined with other pain relieving modalities (which I will come onto in a second). If they're not too painful then progress them into weight bearing exercises, progressing them until you can get them exercising these muscles under extra load, in different planes and speeds dependant on what that patients goals and tasks are, and I won't be giving all the exercises possible or we will be here all day!
But what about manual treatment?
Well I'm going to throw in a controversial bomb here and say that although you can apply manual therapy treatments, it really doesn't matter in my opinion WHAT manual treatment you do for a painful SIJ!!! (I await the backlash)
Yes you can apply an anterior or posterior innominate rotational mobilisation or a scaral thrust or two, even give some ASIS distractions or compressions etc, etc, as there is in my opinion, NO physical way you are really going to make any structural difference to this emmensly strong and stable joint with your hands, steam roller yes, hands no! Even if you do affect the SIJ a tiny bit, as soon as the patient moves to get up off the treatment couch and stand up it will go back to where it wants to and started off in the first place.
Now before you go of your rocker with rage, I'm not implying manual treatment of the SIJ is a waste of time, far from it, it does seem to reduce the level of pain felt for grumbling SIJs, but what I do argue with is that it doesn't make any difference what or which way you do bounce, rub or push on it, as its not the physical effects to the joint that matter, its more the descending neural pain inhibition effects that do. As Steve a fellow physio in Sheffield said recently, it doesn't matter what you rub or prod people with it will help, he uses organic cucumbers apparently!!!
But surely there is some role for the direction of pushing or poking or even the exercises we give depending on what you feel and observe the persons posture or degree of pelvic tilt/rotation to be?
Well again I'm going to throw in another controversial bomb in here (two in one post) and I say NO, it doesn't matter if someone stands with an anterior rotated pelvis compared to a posterior rotated one, or even if one side is higher than the other!!! (I await an even bigger backlash on this one!!!) and possibly just possibly I might releant on on the 'one side being higher than the other one' if due to a leg length difference, but it has to be a significant one eg 15-20mm different before I'll consider it. This paper by Preece et al 2008 on pelvic morphology just sticks in my mind when assessing the pelvis that bony landmarks are so unreliable.
Anyway, so, pull and poke painful SIJs but with no real clear idea or direction in mind, do it on trial and error basis, push a bit this way, get them up and moving a bit, ask if it feels any better, no, ok get them back down, push the other way etc etc.
Now some may say that this method I use is due to my lack of skill or experience or that I haven't got expert super duper 'feely' hands or some extra perspetory skills that some other therapists have! I say nope that's aload of crap, it's just me being realistic in realising no-one can clearly say they can tell which way a SIJ needs to go or which way is going to help, so why limit yourself and possibly miss helping someone out of pain just because of some rubbish tests and personal pride, push that bugger in all directions until something feels better for the patient, simple!!!
So in summary I'd argue the only way to treat a true and rare painful SIJ is with exercises for the muscles in and around the the trunk to increase the resiliance of the soft tissues (muscles, ligaments etc) around the SIJ to withstand load and stress across the joint. The exercises you choose I don't believe make much difference but should be chosen depending on the level of your patients pain, irritability and skill. They want to be progressed into loaded, multi directional and varying speeds, dependant on your patients goals, tasks and activity. Manual therapy can be used to relive a painful SIJ but not on the pretence that you are affecting the physical properties of the SIJ or that you can only try it in one direction after an assessment as you can sense or feel the dysfunction.
Finally does assessing the posture of the SIJ pelvis and lumbar spine of an individual really help us, or does it just place confusion and doubt into the patients mind for no reason when there is scarce evidence to say that any type of posture is of greater risk or worse than any other?
Food for thought I hope???
Once again thanks for reading