New research: No such thing as "stuck" SI joint

[neuromuscular]

For over one hundred years, after the standing SI joint test showed that the PSIS moved with the sacrum, it has been believed that the SI joint is "stuck" in the majority with low back pain. A simple test is disproving this. Try this: Landmark the PSIS to sacrum and have the patient do hip abduction directly lateral in the coronal plane from closed to the maximum that the patient can achieve At 15 cm increments. In virtually all of the patients with a positive for a stuck SI joint the PSIS will move superior and lateral to the sacrum. When the PSIS to ASIS is measured on the side of the supposed stuck SI joint, the innominate bone will move into anterior rotation.

The true condition of the patient is better described as APAS, asymmetric pelvic angle syndrome. The research paper on this is being prepared.

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[alophysio]

Thanks neuromuscular.

As you know, i have given you feedback about your test.

However, perhaps addressing some of the concerns i raised in the previous post might help others see that you are "balanced" in your approach...at the moment, it seems that you are "pushing a barrow"

Perhaps trying to see things from other peoples point of view can help.

For example, can you see how not referencing the sacrum in your test means it is difficult to determine SIJ movement and that the rotation can be coming from the hip? Therefore it is difficult to say with certainty that the SIJ is NOT stuck because there are other explanations...

Your ideas are good - i just think there needs to be balance...

[neuromuscular]

Additional Comment I forgot:
Dear ALOphysio:

I have given you reply some thought.

I would disagree with the idea that the inter-person results being similar is proof that the test is reliable. How so?

Hungerford may have found that all people conditioned to believe that the test is accurate got similar results. Pavlov did that with dogs when a bell rung at feeding times.

Science is not about being sweetie pie to everyone when they dish out gall.

Science is about what is accurate and what is not.

If we took a bus load of people into the outback in Australia who had never been out of the city, what would they "see" as they drove down the highway on a hot summer ( December to March) day? Would it not appear to all of them and would not all be in agreement that the road appears to have a layer of water on the road when in fact is is the refraction of light???????

So having every one agree that they saw the same thing does not make it so!!!

In the standing SIJ or stork test every one "sees" that the PSIS moves with the sacrum in hip flexion or torso flexion as a positive for joint problems. What does that prove??? Is it really a joint problem or not???

In the same landmarking with hip ABD the PSIS moves superior and lateral to the sacrum. What does that prove???

What is really the fact in this case? Is the joint stuck in one test and clear in the other or is there a false positive going on and we are ignoring the facts???

I humbly suggest that you try the two test back to back and decide for yourself and others do the same..

Try the standard test of the SIJ with hip flexion and torso flexion and then landmark the PSIS to sacrum with hip ABD. For every stuck joint, the PSIS moves superior and lateral in the second test. Period.

WHat does this suggest???

My best to you,

Neuromuscular.

[neuromuscular]

Dear Alophysio:

I have given your reply more thought and it is obvious that you have not tried the comparison test of the SIJ that I have stated several times.

The APAS test or innominate bone position test is not the equivilant of the standing SIJ test, but I did state one that is.

To test the SIJ positives of the standing SIJ test or stork test you can do the following back to back:

Step one: Patient standing Practitioner landmarks the PSIS to sacrum. Patient does hip flexion and torso flexion while the practitioner maps the PSIS to sacrum. The standard standing SIJ test or stork test.

Any positives can be directly compared to the following:

Step two:

Patient standing. Practitioner landmarks the PSIS to sacrum. Patient does hip ABD to the ability of the patient to comply at increments of 25 cm, 50 cm, 75 cm, 100 cm, etc.

My results: ALL patients with a supposed stuck SIJ or "fixation" of the SIJ had the PSIS move superior and lateral to the sacrum in step two. What is your take on this phenomenon??? I see the supposed positive in step one as a false positive and has an easy explanation.

Science is out getting the facts.

Science is about accuracy.

Science is about verifiability.

Science is about knowing the full picture.

PLEASE READ THIS CAREFULLY AS THE TEST GIVEN IS NOT THE APAS TEST.

My best to you,

Neuromuscular

[neuromuscular]

To All:

Let us be sure that we are all on the "same page".

The comparison test done to challenge the popular ubiquitous standing SIJ test or "stork" test is as foolows:

Step one:

Do standard SIJ test with hip flexion or torso flexion or both.
Patient standing. Practitioner landmarks the PSIS to sacrum from the posterior. Practitioner maps the SIJ of the PSIS to sacrum as hip flexion and subsequently the torso flexion is performed by the patient.

Step two:

Patient standing. Practitioner posterior to the patient landmarks the PSIS to sacrum. Practitioner maps the PSIS to sacrum as the patient does hip ABD to the following positions: 25 cm, 50 cm, 75 cm, 100 cm, to the ability of the patient to perform hip ABD. Practitioner maps the PSIS to sacrum through the entire hip ABD.

Note the positions of the PSIS to sacrum in each phase of the tests. Note any differences. What is your conclusion???

This IS comparing "apples to apples".

Do the APAS test to find out if you are missing other pertentant information on your patient/client.

Best regards,

Neuromuscular.

[neuromuscular]

To All:

I would like to add that repeatability and inter-tester results ARE important ONLY IF THE TEST IS UNQUESTIONABLY RELIABLE. The stork test or standing SIJ test with hip flexion or torso flexion fails in that the same landmarks do a different movement in the same test with hip ABD.

My question is: How can this supposed "stuck" SIJ or "fixation of" the SIJ move apart in the second test if the first is accurate???

Inter-tester repeatability is important when the test is verifiable, accurate and has no loop holes. It is a scientific tool.

Please note that some have missed this part of the assessment.

My best to all,

Neduromuscular.

[alophysio]

Dear Ed,

My friend, i HAVE done your test.

Again, it is not new to me because i work on principles, not following what someone says to do.

I test the PSIS and sacrum to all sorts of tests (in addition to other landmarks as well) as a test of LOAD TRANSFER.

My interest is in the joint and whether it is well controlled.

I am sure i have written here and to you privately that the cases of a "stuck" SIJ are rare and that motor control problems give the appearance of unlocking.

I too am frustrated by what people believe however have no fear - i am not dismissive of your claims, just critical - as all good scientists are my friend.

In your assertion that you have never seen a stuck SIJ, some logical conclusions result;

1. You are correct and there have not been any stuck SIJs come thru your clinic in all your years
2. You are incorrect and there HAVE been stuck SIJs but you have incorrectly assessed them

In addressing #1, there is nothing left to do - it would assume that your assessment of the SIJ is valid and reliable and correct. I believe you live here and truly believe this.

In addressing #2, i am not so sure you have fully considered all the possibilities...like
a. When you see the PSIS move superior to the sacrum - is it relative movement of the innominate compared to the sacrum or the whole pelvis rotating or twisting or simply a myofascial pull?
b. Your passion and emotions would beg the question...are you too close to your test to be objective? Honestly, you have addressed some scientific questions i have about the test but have you addressed the communication aspect? Insulting me and others certainly doesn't make me feel good about doing things for you or to even validate your test. However, i feel i understand you better than that which is why i have kept communication lines open...how many people have you found that have been as generous towards you as i have? It is not just because i have taken the time to be nice but perhaps your communication style puts people off...

Please consider...

thanks

[neuromuscular]

Dear Alophysio:

The proper protocol on a thread is to use the code or user name on the thread, even if you do know the person by their given name.

My concern is that we are conditioned no matter how hard we refute the idea. It is like Lady Macbeth where it was said of her: "Me think the lady doeth protest too much." We can jump up and down and stand on our head, but peer groups condition us to accept the ideals of the peer group, so we find it hard to think "outside of the box".

On integrity, I am sure that Ptolemy was a man of integrity that believed that he was seeing the corect perspective. His theories and subtheories for the divergencies that he was seeing were very involved and seemed very correct. However, when Capernicus and later Galelio said that the very first assumption was not correct, the whole gagle of theories fell like a house made out of a deck of cards.

You appear to have read every author in the realm of physical therapy. I may not have read as many. Myk Hungerford's study that showed that there was conformity to the rules and that every tester came back with close or similar findings does not impute lack of integrity, but possible tunnel vision. If you frame a test to give certain results under certain conditions, it is like the bus load of people who all saw the reflected light off the pavement and thought it was "a layer of water" on the pavement. They all had the same findings. What would Myk Hungerford have found if they did the same test with hip ABD instead of hip flexion or trunk flexion. We do not know, because Myk Hungerford did not try that part of the comparison test!!! Why? because it was 1) unknown to her - she was ignorant of the implications of doing the comparison of hip ABD to the other way of doing the standing SIJ test, because her peer group had never considered it!: 2) she thougt it irrelevant for whatever reason. We may never know.

The movement of the PSIS away from the sacrum is relevant unless you wish to dismiss it. It is movement of a supposed "stuck" joint. How???

Load transfer tests to my experience are very inconsistent and subjective and carefully framed.

Science is being accurate and open to new ways of looking at things: not recyling old ideas to make something fit. Ptolemy made that mistake.

What are the reasons for reconsidering if a new perspective is needed? Numberus sources are showing low sucess rates in trial after trial of therapy for low back pain by several disciplines - load transfer testing et al (27.5 to mid 45% rates). ( I have quoted these, but others have dismissed this. Is it an ego problem? ) That should be reason enough to contemplate a new direction on its own. Further, Andry vleeming chairs an international convention on low back pain. If the treatment of low back pain were a "sure thing", why have a conference looking for new ideas???????

I feel that there is enough evidence, and the the comparison test is just one more test to question the status quo.

Best regards,

Neuromuscular.

[alophysio]

Dear Neuromuscular,

Apologies about the tag - going between email and this got me into trouble...

1. The SIJ moves - we know this and there are tests that are there in the research and some research to prove reliability and some research that does not support reliability - you said yourself you haven't read the research - go and read at the least the abstracts - pubmed.com

2. The pelvis moves relative to the L5 and relative to each hip joint.

If you can acknowledge these points and that your test deals with both of these types of movement (internal and external) then fine.

If you cannot agree on these two points and your test, then i believe it is you that protests too much.

Good luck neuromuscular...my patience is wearing thinner...

[neuromuscular]

Dear Alophysio:

I did not say that I have never read the research. I said that I have not read as much as you.

The point of interst is that the standing SIJ test with hip flexion or torso flexion is at odds with the same landmarks of PSIS to sacrum with hip ABD. That is the point of interest. In the standing SIJ test with hip flexion or torso flexion a positive beomes a negative in the standing SIJ test using PSIS to sacrum with hip ABD. How would you prove which one is the true "positive" of "negative"???

I find load transfer tests or weight transfer tests as too orchestrated to be unbiased. Which one would you prefer to be used? Why that test? What would it prove?

Further, I find that the anterior rotation indicated in the standing APAS test is from a contralateral side and unlike the common viewpoint that the anterior rotation of the innominate bone is from an ipsilateral cause.

That is of major impact on therapy.

Best regards,

Neuromuscular.

[alophysio]

Hi Ed,

Refer to my last post and the 3 points above...you haven't addressed them yet...

Here they are again...

1. The SIJ moves
2. The pelvis moves relative to the L5 and to each hip.
3 Your test assesses movement of both point 1 (SIJ) and point 2 (L/S and hips).

Do you agree or not?

[neuromuscular]

Dear Alophysio:

I believe that Ola Grimsby, as numerous others, has advocated and I believe has proved that the SIJ does move.

I have no problem with the concept. After all, why would a joint be where it is unless there was some sort of movement???

The innominate bones move relative to the sacrum and to each other. That is well attested to.

The test assesses movement not a "stuck" joint. It shows that the concept of "stuck' is not so. It shows a different cause than proposed by the "stork" test.

I am not sure why this is asked.

Best regards,

Neuromuscular

[alophysio]

Neuromuscular,

What research has Ola Grimsby published? A search of Pubmed.com under "Grimsby O" produced nothing in the way of research on SIJ motion.

If you want to quote people who have proved that the SIJ moves, then do it properly - Sturesson for example who implanted metallic balls into people's pelvises...

With all due respect to Ola Grimsby, he is not the authority on SIJ motion...

You haven't addressed point 2 and 3...

2. The pelvis moves relative to the L5 and to each hip.
3 Your test assesses movement of both point 1 (SIJ) and point 2 (L/S and hips).

Again, the "stork test" in recent research is about FAILED LOAD TRANSFER - of which the causes are neuromyofascial and articular (fixation is a subset of articular causes).

See "Hungerford B" at PubMed Home - the articles are #2, #3 and #4 on the list as of today...

I have my evidence that my statements are accurate - that is, the stork test is for failed load transfer...AND they are published in the literature in the public domain...

...you state the stork test is for a fixated SIJ - where is your evidence?

You are attacking a test without basis by claiming the test claims a fixated pelvis when the published literature contradicts you.

I ask these questions of you because if you want to be taken seriously, then do serious work and at least read other people's research before you attack them...

Your test has flaws. I am DONATING my time to help you. If you are going to soak me for information, at least answer my questions!

You haven't addressed point 2 and 3...

2. The pelvis moves relative to the L5 and to each hip.
3 Your test assesses movement of both point 1 (SIJ) and point 2 (L/S and hips).

[neuromuscular]

Dear Alophysio:

First, Ola Grimsby may not have published the work, but was involved in it. Yes Struessen was the person to do most of the offical publication. Ola has produced several books.

Second, with all due respect, you have not addressed by proof why the standing SIJ test with hip ABD gives differring results to the beloved standing SIJ test with hip flexion or torso flexion.(stork test) You have quoted only those who are "pro" "stork test or advocates of the "stork" test.

My whole point is: why the difference? One says there is a problem ( stork test), the other says No problem (hip ABD test). Why?

Several texts state that the test is of SIJ "fixation" or a "stuck" SIJ including the text ORTHOPEADIC PHYSICAL ASSESSMENT by David Magee. Every medical practitioner that I have talked to has been taught that the test is for a "fixation" of the SIJ. Chiropractors are taught that the test is for a "stuck" SIJ.

If you want to sublimate this by saying LOAD TRANSFER By all means do so, but show why other tests differ from it. That is the point.

Yes the pelvic bones move relative to other structures.

I would like people to try the tests and then formulate why the difference and then address why the test results differ. Just stating research that has not addressed the test using hip ABD does not discredit the test or its results. The hip ABD test casts a great doubt on the "stork" test.

All research to the present has ignored hip ABD. Regardless if you do the comparison test of PSIS to sacrum with hip ABD or the APAS test, the results differ from the standard "stork" test. Why? Yes the planes are different, but it should corroberate the "stork" test and not differ.

That is the whole point of the discussion. No one has done the hip ABD test in research to the present. It has not been published, because no one has done a trial on it or has viewed the hip ABD as relevant. Why???

The status quo is accept the "stork" test, because we say so. We have "figured out" just what it is - a LOAD TRANSFER TEST, so it has to be so.

Best regards,

Neuromuscular.

[alophysio]

Thanks Neuromuscular,

Now we can move on to the next stage.

By your admission, the Stork test as described in recent literature is a LOAD TRANSFER TEST - which by definition has many causes, one of which is fixation.

The next step is that you claim you can see one result on the stork test (positive failed load transfer test) but "movement" on your APAS test.

By your own words, you have merely confirmed my position!

I find that the standing SIJ test or STORK test gives results that differ from the same landmarks with hip ABD. (This is not the APAS test or innominate bone position test, but just a comparison of the standing SIJ test to the same test with hip ABD instead of flexion to compare how the joint moves or does not move.). So if one does the standing SIJ test with hip flexion or torso flexion and does a comparison to the same landmarks of the PSIS to sacrum with hip ABD, the PSIS moves superior and lateral in the vast majority of people examined. What does this indicate? A false positive in the standing SIJ test with hip flexion or torso flexion vs the same test with hip ABD???? If it is a false positve, should we not be concerned???

- from post #25

In other words, if you read the research on the Stork test by Hungerford, she too observes that failed load transfer results in anterior rotation of the innominate (superior and lateral movement)...

In other words, a positive stork test is the same as your APAS test.

QED...

[neuromuscular]

Dear ALophysio:

Thank you.

However, unless we are talking about two different things, the postitve from the standing SIJ test with hip flexion and/or torso flexion is that the innominate landmark of the PSIS and the sacrum move as one unit together. How can that be the same as the PSIS of the innominate bone moving away from the sacrum in the comparison test ( which is not the APAS test) where the PSIS to sacrum landmarks are observed during hip ABD? I do not follow how a joint moving together as one unit is the same as the same joint moving apart (the bones moving seperately)???

Best regards,

Neuromuscular.

[alophysio]

Hi Neuromuscular,

No, we are talking about the same thing.

+'ve stork test (stance phase - where you measure the PSIS and sacrum on the stance leg, not the hip flexion leg)
= unlocking of SIJ = counternutation of sacrum relative to innominate or anterior rotation of innominate relative to sacrum

In other words, what you described above in your APAS test...

...which simply means stork test +'ve can produce the same results as your APAS test

[neuromuscular]

Dear ALophysio:

Thank you for your reply.

You speak only of the one type of standind SIJ test - with hip flexion - and ignore the standing SIJ test with torso flexion. Why?

I have given data on the percentages with the APAS test. Can you tell me where there are any similar breakdowns on findings with the stork test - Myk Hungerford, Dianne Lee or standard variety? I have not seen them.

The torso flexion variety of the standing SIJ test is a stance phase also. How do you view its results?

I like the hip ABD for the reason that the data is produced in repeatable and in segments that allows the practitioner to consider what is happening at a slower rate. I find that the others happen too fast and aspects are missed or misread.

Nest regards,

Neuromuscular.

[alophysio]

Hi Neuromuscular,

Yes, i speak of one SIJ test because it is research-based and validated. The others have poor reliability but that is in its conclusion, not the testing. I use STANCE PHASE SIJ assessment during contralateral hip flexion but you could do other hip movements with the same assessment...including hip ABD

For instance, standing flexion test with PSIS and S2 landmarks - so many other things get in the way that you don't really get a good idea of what it is that is causing forward bending test results to vary...you can take out the most obvious reason - hams pulling on sacrum via sacrotuberous ligament by re-doing the test with slight knee flexion. It works but i the tests i do are just fine thanks - just do the stance phase stork with light knee bend on the stance leg and it takes out the hams and gives you an idea of where to go.

You can quote your own % as much as you want but if you want people to take you seriously, then publish the results and have it peer reviewed. I can tell you that i have success at identifying 95% of problems my own way but how much are you going to trust me?

Hungerford's name is Barbara by the way, not Myk and Diane Lee's name has 1 'n' only...

your test is static, my test is dynamic - can't say is better than the other i am afraid...

[neuromuscular]

Deart ALophysio:

It is interesting that you agree that the diferent phases of the test show differing results or produce confussing results. Then choose to do only the one that you feel is accurate. Why eliminate the other phases or minimize them? On what basis???

I had been using this test prior to the hip ABD test. However, the hip ABD test does NOT give confusing results, but a progression of results that concurr with each other rather than give differring results.

The standing SIJ test is an OLD test to be sure, but "proven", much less so. Every "expert" has a different spin on the test that is more "accurate" than the other "experts". Is this not like Ptolemy and the subtheories to prove the discrepancies???

Most others use the "swing" phase mr torso flexion, from the people that I have talked to, if you wish to use the currrent designation by some, but you prefer the "stance" phase. In reality, are you not seeing only half of the information? Are you not picking and chosing what information you consider to be accurate???

Did you really give the hip ABD test and the APAS a fair and unbiased approach? Or was the jury decided before the test was tried??? You like the published "experts". Can you consider something on the basis of its own worth???

Our bias often shows and we charge others with bias. As I have said, I have tried the standing SIJ test with hip flexion and torso flexion - for an extended time before i happened on the hip ABD test Each gives information that does not totally coincide with the other "phases" of the test. Should we each pick and chose which phase of the test we will consider to be the "accurate" phase??? On what basis???

Could this be why you do not see the results from the hip ABD test as very relevant? Must the test be accredited by every Tom, Dick and Harry to be "acceptable'??? Book knowledge has been stated as living inside the box and not being able to see outside the box. Do we need to see outside the box???

I like to look at things from what the test is telling me. The test has to stand or fall on its own merit and not how much has been published in its behalf. I feel that the older "stork" test is not reliable in all of its "phases", as the terms are today, anymore that it was years ago before everyone called them phases. That is based on its conflicting information from eahc of the "phases" from ipsilateral hip flexion to contralateral hip flexion to torso flexion.

Best regards,

NEUROMUSCULAR.

[alophysio]

Hi Neuromuscular,

Simply put, the stance phase has been validated by peer-reviewed research...the others have not.

I did test the APAS fairly and i resent the insinuation that i had preconceived ideas - have i not always provided you with dialogue? How many people put the time and effort into talking at length about what you want to talk about?

You still haven't tried the stance phase as per the research for 2 weeks yet have you? Are you too biased to try it fairly?

[steve1969]

Even if this test was validated and a patient tests positive - how would my treatment be altered and is there any evidence that outcome would be influenced?

[alophysio]

Hi Steve, not sure who you are addressing the question to...

If it is to neuromuscular, he notes above somewhere how he uses it i think - basically releasing muscles like the adductors and erector spinae and even serratus posterior inferior (although he hasn't spoken of this muscle for some time!)...but it is better left to him to explain what he does with his patients.

As for me, i use the stork test is a modified form for load transfer assessment and go from there...

CHeers

[neuromuscular]

Dear Alophysio:

I have read your email on D Lee et al.

I will address one issue.

First, the overall impression is that nothing is established except bias of I like the stork test, so I use the stork test.

I the articles The evolution of myths...... the statement is made "it is impossible to know exactly which muscles were responsible for the increase in stiffness and compression." page 5. and on page 9 "Therefore, it is still not possible to be totally evidenced based in clinical practice..."
I do not find percentages of the supposed "closures" of closure problems, just hype.

And under the titleThe future it was even more incriminating!!!!

With expressions like " this working group recognized the need for more research... before any controlled trials of clinical outcomes can be done." Sound conclusive to you??? " We need to develope more diagnostic tests..." How conclusive is that?

I am saying that I know the APAS or the innominate bone position test with hip ABD or the PSIS with hip ABD both the percentages of occurances of the abnormal movements and the muscles defined by the occurances. There are no percentages for the "form closure" to "force closure" to "neurological" to "emotional" model. Where are the percentages of occurance? Is this just another smoke and mirrors?

Give me the same percentages I have given you of 90% asymmetrical pelvic angles: 60%; 20%; 20% and maybe I will have something to go on more than hype: I want facts.

Best regards,

Neuromuscular.

[neuromuscular]

Dear Alophysio:

I am finding it hard to get the raw data that backs the "stork" test. As I noted, D. Lee mentions that support is somewhat lacking.

Is there any generated data that gives the percentages of types of disorders seen.

For example:

Test type: Standing load shift or transfer test data "stork test".

Form closure:

type "a" x%
type "b" y%
type "c" z%
etc
etc
etc

Force closure:

muscle or muscle grouping "a" x%
muscle or muscle groupiong "b" y%
etc
etc
etc

Neurological

Type "a" x%
type "b" y%
type "c" z%
etc
etc
etc

Emotional:

type "a" x%
type "b" y%
etc
etc
etc


I find no hard raw data only speculation and quoting froim one or another "authority".

Is this based on solid research data or hypothetical wishes?

I have given you the average percentages with variation factors from group to group. I find nothing such in the supposed testing and form closure/force closure/neurological/emotional field. Maybe I have just missed it.

It leaves a lot to speculation on the part of each therapist. The data I have given is reliable and repeatable patient to patient, group to group and practitioner to practitioner. The test and theory which you like I find less secure in real data terms. I find that the load transfer test leaves a lot of room for error and interpretation unless you take the tunnel vision put forth. I can see the effects of hip ABD and both quantify and qualify it. So can the ordinary person that I show it to who has not been conditioned to accept a certain criteria.

Please show me the data, as I would like to see it.

Have you done a quantification and qualification process on the test???

Best regards,

Neuromuscular

[neuromuscular]

To all:

I am having trouble finding any corroberating evidence for the types of "form" closure in the form closure/force closure/neurological/emotional model.

Does any one know of a catagorization of the types of supposed "form" closure or is this just theory?

I cannot think of how form closure other that in deformed or tramatic injury problems or in the very aged. To me; we all have differring ear shapes and yet the neurological control hears equally well regardless of the shape of the outer ear. Does not the brain tune itself to what ever "form" there is in the individual SIJ and each form works well for the individual? Does "form" figure in prominently or very minimally in this theory? WHy is "form closure" listed first if it is of very inconsequntial proportions?

What evidence is there for a supposed "emotional" part? DO not people become emotionally distraught from not knowing what is wrong with them? Is it cause or effect????????

Please provide any details if you can find them.

Thank you.

Neuromuscular