What is the best way to treat a painful Sacroiliac Joint?

So in my earlier post here I talked about what is the best way to assess if the Sacroiliac Joint (SIJ) is a source of pain, and that using palpation tests to determine if a SIJ is painful or dysfunctional have clearly been shown to be unreliable and of no use. This created a flood, well ok, a little ripple of comments and discussions with some claiming that they can feel the SIJ move and that palpation does give them some useful information in which to direct their treatment.

From this article, one or two people have asked how do I treat a painful SIJ if I do come across one, so this is the subject of this post. Now again I'm sure this will create some discussion and some controversy, so please feel free to comment and give me your experiences and insights but please keep it personable, for some reason the SIJ seems to get therapists fired up more than any other area, I'm not sure why???

Ok let's go…

So the first thing to say here is that I haven't treated that many painful SIJs, I am not claiming to be a SIJ expert, far from it as I can confidently say I could count on the fingers of one hand (ok maybe both) how many SIJ problems I have 'treated' in my career due to there rarity!

I do however get lots of patients telling me that they have been told they have an SIJ problem by another therapist, some have even been told that their SIJ is out or alignment or unstable, which is complete an utter rubbish, and really annoys me that a so called healthcare professional uses these inaccurate and fear inducing terms.

Normally a quick assessment using the pain provocation tests I mentioned in my other post very quickly rules out the SIJ as a source of pain for nearly everyone I see. In my experience it is normally something in the lower back generating pain to be felt around the posterior pelvis, and often there is no firm or conclusive source of the pain, whats call 'non specific low back pain' and this can be frustrating for both the patient wanting a diagnosis to explain why it hurts, and also for the therapist wanting to give something technical as a diagnosis, and to treat, and this is why I think the SIJ gets labelled and blamed way too often! Therapists love a big impressive sounding technical diagnosis, it makes them feel they're using their training and skills to detect something complex and complicated, but unfortunately it's just not!

A recent study by Cohen et al 2013 states that the SIJ accounts for between 15-30% of all low back pain! I argue, because I like to, that it is much less prevalent, this maybe due to my 'normal' clientele being slightly different from that in Cohen's study.

Ok! So what do I do if I have found a rare SIJ causing pain?

Well simply, I get them all doing exercises, great thanks for reading….

 

 

WHAT… WAIT is that it??? I don't I poke, prod or manipulate them, don't I give an anterior innominate rotation thrust or a posterior torsion mob here or there….

Well, no I don't, I cannot remember the last SIJ manual treatment I gave, if I do decide to do any manual therapy, its NOT to correct or attempt to change or alter its position and its definatley not to 'loosen' or free it up, let me explain why.

Firstly if we look at the anatomy of the SIJ closely, as in this paper by Vleeming et al 2012 does very well, we can see that the congruity of the bony surfaces, combined with the many strong ligaments that cross it, make the SIJ a very, very stable joint, it has to be, it transfers a lot of force and load from the legs to the trunk and visa versa, this is termed the SIJs form closure ie its shape and structure.

However, the joint also requires the contraction of muscles around it to help control the small amount of movement that is available to allow the effective transfer of stresses across it, this is what's called force closure, read more in this paper from Wingerden et al 2004 on that.

So in summary the SIJ wants to be stiff and stable but it also needs to move a teeny tiny little bit occasionally.

Now the two main reasons why the SIJ is thought to cause pain is either due to excessive movement causing shearing forces between the joints articular surfaces, and I use the word 'excessive' here with caution, as the SIJ doesn't move much at all, on average about 2-3 degrees, thats about 3-5 millimetres of movement, but it is still thought to be enough to create irritation.

The other reason its thought to cause pain is that the SIJ becomes too stiff, stuck or jammed and the little bit of movement that it is supposed to have isn't available and so creates pain.

But are these theories correct!

Now, Greg Lehman an excellent physio, chiropractor and an ex researcher, has shown me that we can't say excessive shearing or extra movement at the SIJ causes pain. (Follow Greg here on twitter, and go visit his excellent site here)

For example this paper here by Damen et al shows that SIJ laxity, which is common during and after pregnancy, isn't correlated with SIJ pain, they found pregnant women with severe pelvic pain had the same amount of laxity as those no pain, so proving we can't just blame SIJ laxity for the pain!

Next, the strength need to produce force closure by the muscles around the SIJ are not very much at all, and so cast big doubts on the theory that muscle weakness can leave it vulnerable to laxity and shearing forces. Actually most muscles around the trunk when they activate even gently create enough force to close the SIJ as shown by this study here by Richardson et al showing that if they can stand up they can produce more than enough force to stabilise the a SIJ!

So if not laxity, shearing forces or weak muscles causing the SIJ pain, what about it being stiff, getting stuck or not moving enough?

Well I question how is this is even possible, and if it is, how do we know its stuck? I have already discussed in my other SIJ article that there is no way of palpating or feeling a SIJ move or not move so we can never tell if its stuck, and a too stiff SIJ just doesn't make sense to me, the SIJ wants to be stiff and rigid, if its too stiff why would that cause pain? And how on earth does it become stuck as some claim, does something get inbetween the joint, highly unlikely in my opinion.

So if not due to excessive movement and not due to it being stuck then why does then SIJ cause pain? Well simply I think its due to plain overload and excessive forces across the joint that it can't handle, so nociceptive nerve endings around it complain, it's as simple and straight forward as that, no excessive this, no stuck or stiff that.

So how do we treat it?

Simple, as I said earlier, exercises, to build up the SIJs resitance to take an increased load by increasing the soft tissues capacity in and around it. Which muscles you choose to do will be based on individual severity and irritability and their pain provocation patterns, skill levels and goals but in a nut shell I dont think it matters too much, as we know from that earlier Richardson study all the trunk muscles have a role in producing SIJ force closure. But usually in my experience the muscles of the posterior oblique sling are the ones lacking, most people I meet are weak in the posterior chain and so these are the ones to focus on more, such as the Latissmus Dorsi, Hamstrings, Glutes and of course the large powerful Erector Spinae muscles all of which act on the thoracolumbar fascia.

Image courtesy of saveyourself.ca

How you go about this is up to you, it is obviously guided by the levels of pain the patient is in, if really sore, then non weight bearing strengthening of these muscles can be used to start with until the irritation settles combined with other pain relieving modalities (which I will come onto in a second).

If they're not too painful then progress them into weight bearing exercises, progressing them until you can get them exercising under extra load and resitance, in different planes of movement and variable speeds dependant on what that patients goals and tasks are, I not going to be giving all the exercises possible or we will be here all day, but exercises like bridges, deadlifts, kettlebell swings, lat pull downs are all great moves.

But what about manual treatment?

Well I'm going to throw in a controversial bomb here and say that although you can apply manual therapy treatments, it really doesn't matter in my opinion WHAT manual treatment you do for a painful SIJ!!! (I await the backlash)

Yes you can apply an anterior or posterior innominate rotational mobilisation or a scaral thrust or two, even give some ASIS distractions or compressions it doesn't matter as there is NO physical way you are going to make any structural difference to this emmensly strong and stable joint with your hands, steam roller yes, hands no! Even if you do affect the SIJ a tiny bit, as soon as the patient moves to get up off the treatment couch and stand up it will go back to where it wants to and started off in the first place.

Now before you go of your rocker with rage as I've just ridiculed your training and skill, I'm not implying manual treatment of the SIJ is a waste of time, far from it, it does seem to reduce the level of pain felt for a grumbling SIJ, a little bit, for a short while.

But what I do argue with is those that feel they can assess which method or direction of manual therapy is best based on physical assessment and palpation tests,

Simply put it doesn't make any difference what or which way you bounce, rub, push, poke or pull on an SIJ, its not the physical effects to the joint that matter, its the descending neural pain inhibition effects that do!

But surely there is some role for the direction of pushing or poking or even the exercises we give depending on what you feel and observe the persons posture or degree of pelvic tilt/rotation to be?

Again I'll say it NO, it doesn't matter, even if you think you've found someone standing with an anterior rotated innominate or a posterior rotated one, or one higher than the other etc etc, as using these bony landmarks to guide your reasoning in deciding on an SIJs position is unreliable and is no more than palpation fantasy as neatly demonstrated by this paper by Preece et al 2008 who found wide normal anatomical variation in the angles of the ASIS and PSIS.

So what do I do, well if I decide on a rare occasion to give some manual therapy on an SIJ, I simply pull and poke it with no real clear idea or direction in mind, I do it on trial and error basis, push a bit this way, get them up and moving a bit, ask if it feels any better, no, ok get them back down, push the other way etc etc.

Now some say that I use this method due to my lack of skill or experience or that I haven't got the expert super duper 'feely' hands or the extra sensory perseption skills that other therapists have! I say nope that's aload of crap, it's just me being realistic and honest in realising that no-one and I mean no-one, can assess clinically and tell which way a SIJ needs to go or which way is going to help! So I say why limit yourself and possibly miss helping someone just because of some delusion of skill, some rubbish tests and personal pride, I say push that bugger in all directions until something feels better for the patient, it's that simple!!!

So in summary I'd argue the only way to treat a true and rare painful SIJ is with exercises. The exercises you choose I don't believe make much difference but should be chosen depending on the level of your patients pain, irritability and skill. They want to be progressed into loaded, multi directional and varying speeds, dependant on your patients goals, tasks and activity.

Manual therapy can be used to relive a painful SIJ but not on the pretence that you are affecting the physical properties of the SIJ or that you can only try it in one direction after an assessment as you can sense or feel the dysfunction.

Finally does assessing the posture of the SIJ pelvis and lumbar spine of an individual really help us, or does it just place confusion and doubt into the patients mind for no reason when there is scarce evidence to say that any type of posture is of greater risk or worse than any other?

Food for thought I hope???

Once again thanks for reading

Happy exercising

Adam

 

 

56 thoughts on “What is the best way to treat a painful Sacroiliac Joint?

  1. Hi Adam,
    Thanks for a brilliant article. From a personal point of view I would like to back up you statements that exercise does help SI joint problems. I had problems for many years until I discovered light exercises that helped that area, similiar to the ones your mentioned: glute bridges, alternate arm and leg raises etc… I would follow this with ice and try to alternate the exercises each day. As time goes on more and more can be done. I eventually progressed to light dead lifts which I am so impressed that you mentioned, They really helped me towards the end of the recovery, everyone I spoke to said I was nuts!
    The SI joint has gone on me again recently and I am back into light exercise again. I have to start all over as I had forgotten all of the above, I have had to retrace my steps to remember what really worked. For the last six months I have done a lot of classical Pilates on the reformer which has strengthened the abs and pelvic floor but has not really done the muscles on the back of the body at all. It hasn’t really been as good as I thought and as we speak I am just starting to get back into the ones done previously and it’s great to get confirmation from your article that these are the areas one has to concentrate on. Thanks again,
    Reg

    • By the way, any thoughts on what should be stretched along the way? Another post mentioned piraformis, hamstrings and psoas, all of which seemed to make sense. My psoas and adductors have been super tight over the years.
      Thanks Reg

      • Hi Reg

        I am quite controversial in that not a fan of stretching much at all, especially static stretching, I don’t think it offers much, to maintain flexibility we need to just move. Also strength training has been found to be a far more effective way of maintaining flexibility than static stretching.

        Also we have to ask ourselves what causes the sensations of stiffness and tightness, research is now showing us that actually its a weak and overloaded muscle that sends distress signals to the brain saying its feeling the strain, the brain interpret these signals as stiffness and so get you to stretch, when in fact really what the muscle needs is strengthening to stop the distress signals being sent in the first place.

        So don’t stretch, strengthen more.

        Cheers

        Adam

  2. Thanks for writing this detailed post on ways to treat a painful Sacroiliac Joint, and the top image also build my basic understanding on joints and other related elements as well.

  3. Hi,

    Just want to say your blog is awesome. I’m just a band 5 with just over a years worth of MSK experience (a few years elsewhere in other physio roles), ergo I know hardly anything about treating the SIJ (I probably know hardly anything about most conditions – it sure takes years and years before you become anywhere near an expert on anything!?). I have (or thought I had) a few SIJ patients on my case load at the moment, so this blog is really interesting. The little I have learned about the SIJ is from my own self directed learning (hence coming across this article) and mostly from supervisors and colleagues. I have found learning from others though, can be frustrating. Some of these physiotherapists, who are undoubtedly experienced in their fields, are very set in their ways and many, despite being advocates of ‘evidenced based practice,’ still do treatments that have little or no evidence to support their treatment choice. Some of the best physiotherapists I’v found in my limited experience are the one’s more ready to admit they do not know what is wrong with the patient. Sadly, there are many, in my opinion, who are arrogant and have a ‘superiority complex’ (thank god I can stay anonymous here!) – a term, a senior physiotherapist with a PHD under his belt, once said to me when voicing similar opinions, whilst I was a band 3 – only now am I realising the truth of this. I thought the last paragraph of your article was definitely food for thought – for example, ‘postural dysfunction’ must be one of the most common diagnoses that physios’ use (if we exclude “mechanical back pain” which must be one of the vaguest), which may well be a true diagnosis (again I’d like to emphaise my lack of expertise in this area), but how many of us have perfect posture? And why, when we do not have this perfect posture, do we not all suffer the same pains and problems others do? (another blog subject maybe?) I’m probably boring the socks off you now if you or anyone else even reads this. I just wanted to say thanks for the awesome blog, physio shouldn’t be monolithic and should be open to controversial debate! Hope this doesn’t all sound too obsequious.
    Thanks again,

    Racheal

    • Hi Rachael

      Thanks very much for your kind comments

      I must admit I had to google obsequious… But no not at all!

      All the best with your career, keep that open inquisitive mind strong, bite your tongue often with fossils that refuse to change and keep asking the difficult questions and you will be fine

      The only certainty is uncertainty and start to get comfortable feeling uncomfortable

      All the best

      Adam

  4. Adam, what do you make of leg length differences, upto 2 cm between legs, right shorter ostensibly caused by wrongly rotated innominates? Palpation (which you hate) shows left side is anterior, right is posterior. The illiac crest on right is higher and ostensibly the cause of all the issues (LLD). palpation/techniques per the book “malalignment syndrome” show inflare on left, outflare on the right, how would you assess the path forward for such a case? I am the one suffering, because i had some unecessary manual mobilization and all this was the result. I sort of disagree with you that all this does not matter or is placebo, let me explain. before my manual therapy based on MET, my xray showed spine tilting to the right. MET/mobilization changed my pelvis position and now i am tilting to the left. its not in my mind but on xray film. so presumably misbalanced rotation of the two sides of the pelvis can cause issues. your thoughts welcome. since right now, attempts to fix it with MET are going nowhere as i am told a complicating factor may be some sacral torsion and what not.
    your mention of thoracolumbar force closure makes ample sense. actually you are saying the same other folks are saying. their back muscles are perhaps so weak they completely rely on the sacral-muscle-lig complex to achieve this. and hence the end result is improper closure, biomechanics. in your method, you make sure there is enough support to get the job done by getting the entire ecosystem activated.
    however, the question is how does one fix badly aligned pelvis/misaligned rotations etc on either side? also, in your experience is it possible to jam the sacrum in some pattern (left on left torsion etc) or is that plain hyperbole?
    thanks

  5. Thanks for the info. I have psoriatic spondylitis, All of pain is in my SI joints. I just had a SI joint injection 3 weeks ago and just yesterday my pain is back again. I know i can’t just keep getting injections so I need to try other things for pain relief. Thanks for the tips

  6. i’m glad some of your patients find relief from exercise. However I’ve been damaged by physical therapists who believe that all back and SI joint pain can be cured by exercise. I’ve been suffering SI joint pain for 8 years following pregnancy, I am a practicing scientist with a Ph.D. and I have studied this problem extensively. This is not a joint that is stabilized by muscles. It is held together by ligaments. They can become loosened by injuries, age, or pregnancy. Sprained SI joint ligaments are easy to diagnose – the posterior ligaments are on the surface of the low lower back and you can dig your fingers into them and feel the pain. The ligaments can also swell and squeeze the nerves to the legs and cause referred pain. Exercise makes it worse, not better. This is the case with all ligament injuries. Or tendon injuries. Or muscle injuries. They require a certain amount of rest to heal. Not all back pain and SI joint pain can be cured by exercise. I wish it were true but it isn’t.

      • Well that’s a cop out… If you are truly interested in educating people on your theories and dispelling what you consider to be “erroneous beliefs,” then climbing down off your soap box and engage in discourse with people who refute what you are saying. Don’t just run away and hide from other points of view.

        I, for one, support her statements. I am a yoga teacher and therapist, personal trainer, as well as someone who has struggled to manage SI dysfunction for over a decade. Why are we wrong? Or are you merely unable to come up with a response and hiding behind your dismissive comment?

        • Soap box? What soap box??? And what exactly is your question?

          If you are truly interested in debate around why the notion of many assessments and beliefs around the SIJ are flawed, unreliable and inaccurate, you would not start with personal comments and ad hominem!

          I’m not hiding, my views on assessment and treatment of the SIJ are very clearly presented here with supporting evidence and explanations as why I think those who peddle myths to yoga teachers, personal trainers etc are wrong!

          By the way what sort of therapist are you and what teaching in anatomy and physiology have you had?

          Please read the evidence and papers I have presented here then get back to me with a specific question without personal comments, and maybe we can go from there!

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