OK, so the SIJ moves. How best to assess what moved where?

[Physiobase]

Thanks everyone for the comments on the SIJ. I think we all agree it does move, albeit not much. I think we can postulate that it might be a direct cause of pain and is likely to be, at times, an indirect source of pain.

So how best should we assess it. Let's add our thoughts and experience for the evaluation of what moved where. After we do that we can then talk treatment approaches.

Over to the global panel

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[nickhedonia]

physiobase, having been offline for several weeks, I missed the rest of the SIJ discussion and now find it is not in the archive files, can you retrieve this?, thanks.

[MrPhysio+]

If a patient presents with low back pain that radiates postero-anteriorly to the pubis, or laterally around the pelvis to the antero-lateral thigh or groin, suspect the SIJ. Piriformis & lumbar erector spinae muscle guarding tension, and tenderness over the ileo- sacral area is usually present. Sit to stand, sitting, and sleeping pain are common.
Dry needling of trigger points, electrotherapy techniques, muscle stretching, core stability strengthening are the first treatment options. Home gentle mobilisation exercises are given, which reduce muscle tension. If the above fails, a rigid SIJ belt , eg SI-Loc is very helpful. Severe cases requires the use of the belt for 4 to 6 weeks 24 hours per day. The belt must be applied correctly & MUST be tightened in supine, not standing. Gradual weaning of the belt is then advised over a prolonged period, dependent upon symptoms, possibly 4 month in severe cases.
If the belt does not provide any relief on the first fitting in the clinic, it probably won't help, and the diagnosis should be checked. Referral on to a rheumatologist or doctor for the assessment of a cortisone injection is required sometimes.

[mickeyschem]

hi,
check out muscle energy techniques, great to Ax and Rx! should help!

[Physiobase]

I agree but how about we discuss a few of them for those less aware of these techniques. Can you suggest one technique that you feel particularly useful in the management of SIJ dysfunction?

[mageshanand]

there is one technique we use in our set up, position the patient in side lying with affected side up, keep his lower leg straight and rotate his trunk away from away from you till you find the final degrees of rotatory movement at his lumbo sacral joint, then flex his hip and knee to 90 degrees and holding the gluteal region of the patient with your cupped hands in a forward bent lunged position, turn the patient a little towards you, you can either give a sudden thrust or gentle grade 1 or grade 2 mobilization by thrusting the leg posteriorly using your hip(that is where his knee joint would rest), i hope this is clear, if not refer any manipulation book, this is commonly used technique, and other wise as far as assessment goes you can try stokes test, and lots lmore are there

[alophysio]

Hi

Best source i have used is Diane Lee's "The Pelvic Girdle".

What moves where?
Stork Test - Hip F phase:
e.g. R SIJ
Therapist behind patient.
Right thumb on PSIS
Left Thumb on S2
Ask patient to hip F (about 90deg is enough but more in hypermobile
Right thumb (R PSIS) should move down in normals - it indicates that the sacrum nutated which allows efficient load transfer.
If Left thumb moves posteriorly and inferiorly (or stays still), the SIJ "unlocked" or counternutated and thus did not allow for efficient load transfer.

Stork Test - Stance Phase:
Same as for Hip Phase except ask patient to lift the left leg. Same things should happen

I use these two tests as the very basic approach when teaching other physios about the SIJ.

The other really useful tests i use are the ASLR (Active Straight Leg Raise) Test. The various compressions at the ASIS, PSIS and Pubic Symph help to target which core stability muscles you should use.

I would recommend that you do not do a thrust technique unless you really know why you are doing it. Shotgun treatment to the SIJ is not going to help anyone - the patient may have a myofascial compression problem and not a fixation which would just make their instability worse.

If you are in Australia or UK, try to get onto Barbara Hungerford's MET courses or Diane Lee and LJ Lee's courses. I have found them fantastic clinicans and great teachers.
Barb Hungerford: www.amta.com.au
Diane Lee: www.dianelee.ca

What do you others think?

[nzgreen]

Check out "Diagnosis of Sacroiliac joint pain: Validity of individual provocation tests and composites test" Mark Laslett, Aprill, McDonald, Young. Manual Therapy 10 (2005) 207-218. Also available online at ww.sciencedirect.com

[jerryhesch]

I utilize passive accessory motion testing for the SI joints and symphysis pubis. The pelvis as a structure moves in relationship and in concert with the hips and lower extremities and the same is true with respect to the trunk. Gross motion tests do not tell us about passive accessory motion tests. Passive accessory motion tests (spring tests) can only be perfor,med with the body in stable positions, such as prone, supine, side lying and I prefer "muslim-prayer position" over sitting. Gentle force is applied in specific direction to the first resistance point and then the spring test is performed with an additional force. A paper was presented on these tests and on the additional palpatory tests and there is good data, in fact the best with respect to intra-rater reliability which is poor to fair at best with the traditional evaluation methods. It was presented at World Congress Physiotherapy in Barcelona 2003. An outcomes study will be presented in February at APTA combined Sections. The SI has been quite mis-understood and the Muscle Energy model uses a description of joint mechanics that was fully articulated in 1958 by Fred Mitchell, DO, based on a theory of how the SI moves in response to gait. My body of work evaluates an emergent property of the pelvic structure (be it joint - or pelvis as a whole) which is passive accessory motion and treats on the basis of what is found. My philosophy is in line with Gregory Grieve's who stated that ' dOGMA DULLS THE WITS,....we should allow the joint to speak for itself......"etc. This structure does move in ways that have not been described in the popular literature. As my health improves i will contribute more to the literature and make this approach available. For those of you who suspect that is more to the SI joint than the Muscle Energy model describes - you are correct! tREATMENT NEEDS TO TAKE INTO CONSIDERATION THAT THIS IS A VISCOELASTIC STRUCTURE AND mUSCLE ENERGY DOES NOT ADDRESS, cannot address the viscoelastic properties. I utilized low load-long duration accessory motions to treat the structure. I could go on but it is late.
Best Regards
jerry Hesch
The Hesch Method www.heschmethod.com

[alophysio]

Hi!

Jerry, your site was not working at the time of this post so i cannot review your method at this time.

I agree that the biomechanical model is limited but since the original post was about how to assess and treat it, I thought it is a good way to start.

Also, Barb Hungerford does not teach MET exclusively but fits it into Diane's intergrated model of function. From Diane's book, you have...
1. Excessively compressed joints - fixated (often with underlying instability), stiff, compressed (often by muscles)
2. Insufficiently compressed joints - motor control problems or ligament laxity etc.

As far as I am aware, the arthrokinematics and osteokinematics of the sacrum are not under dispute. Coupled movements have been described and nutation/counter-nutation proven and demonstrated in no-pain and pelvic-girdle pain groups.

Reliability tests in research papers often look to quantify dysfuctions and thus show differences between testers but what if they actually studied if there was symmetry or asymmetry (i.e. positive or negative tests). This is more useful clinically. A positive stork test is a general sub-heading for a dysfunction but it feels different for different causes and you see different movement patterns during the test (e.g. L5/S1, SIJ, overactive muscles, poor core stabilisers, tight hip, fixated joint, etc etc).

The Muscle Energy Technique is but one bullet in a stockpile of weapons to use on SI problems. It has been refined and modified. Like your model as described, I treat according to dysfunctions I discover during testing and not so much the pain and symptoms the patient describes (although some Syndey Uni people will tell you that the pain-producing structure is the most reliable way of treating!).

I have taught non-physios (podiatrists, exercise physiologists and myotherapists) how to do the stork and standing FF test and they can do so easily, discover dysfunctional SIJs and refer them off to physios who know how to treat them in a similiar model to the one I use.

Thanks.

[alophysio]

Hi again.

Jerry, your site was working this time!

I agree that passivce accessory motion testing is very important in the assessment and treatment of the SIJ, PS, etc.

Also, Dr Barbara Hungerford's PhD work was on the motion of the SIj during the sotrk test in both the hip flexion and stance phases in people with pelvic girdle pain and in those without. Her work confirmed the nutation/locking in of the SIJ in normals and counternutation dysfunction in those with pelvic girdle pain.

I would be interested to know what your 16 patterns are. Is your system of testing different to that Diane Lee describes in her book "The Pelvic Girdle"? The tests i use are the Standing and sitting FFT, Stork - hip F and stance phases, "squish" test, AP arm test (use force through ASIS), CC arm test (use force along the leg) and another test which is in prone AP via the ASIS while palpating the SIJ (is there a name for this test??).

Are yours similar?