Non-Painful SIJ Dysfunction

8/26/2013

We recently have had a change in stance regarding the assessment of SIJ Dysfunction. In the past, we had been strong advocates for primarily utilizing clusters of pain provocation tests for SIJ Dysfunction as they consist of greater specificity/sensitivity and reliability values than motion restriction tests. In fact, we have even had posts about avoiding those motion restriction tests altogether.

Upon reviewing the APTA SIJ monograph by Jackson and Porter, the topic of non-painful SIJ Dysfunction was introduced. When we assess other joints, we are always accounting for any restrictions present. Take the cervical spine, for example. If a patient has cervical pain, we always assess the shoulder and thoracic spine for restrictions as well and follow up with treatment in the area. The reason being that hypomobility in the shoulder can lead to hypermobility in the cervical spine in order to fulfill movement requirements. This added stress often becomes painful. The same applies to the sacroiliac joint. Low back pain often results from hypermobility, secondary to hypomobility in nearby joints. The hip is one of the usual suspects (and rightly so), but shouldn't we also consider the chance that SIJ restrictions contribute to the excessive motion in the lumbar spine?

Jackson and Porter bring up the fact that there is essentially no research on the topic of non-painful SIJ Dysfunction. Once again, just because there is no research in an area, does not indicate that it should be dismissed as non-existent. We tend to become overly reliant on our pain provocation tests. So what do we do? We definitely recommend still utilizing your clusters, palpating soft tissue, and utilizing subjective information such as Fortin's Sign to aid in diagnosing painful SIJ Dysfunction. As for non-painful dysfunction, practice and implement the motion restriction tests that you are taught in school. We are trained to be competent in tests like Lachman's and Drawer Tests that require identification of differences in movement around a few millimeters. In theory, we should be able to identify some abnormalities in the sacroiliac joint as well. Now, we recognize that research has shown poor reliability for those tests and for good reason, but they may still aide in picking up severe restrictions that will lead to diagnosis and treatment in order to facilitate the return to normal mobility.

Reference:
Jackson R and Porter K. The Pelvis and Sacroiliac Joint: Physical Therapy Patient Management Utilizing Current Evidence. Current Concepts of Orthopaedic Physical Therapy, 3rd Ed. La Crosse, WI. 2011.

8 Comments

Jerome french PT

8/27/2013 11:27:27 pm

I recommend to read the Diane Lee's book "the pelvic girdle" which is a great tool for the lombo-pelvi-hip complex's assesment and treatment.

Chris Fox link

8/29/2013 02:54:13 pm

Thanks for the suggestion, we will be sure to look into it! Check out the reference listed above by the APTA's Ortho section as well, it's pretty comprehensive!

Steve

8/29/2013 03:36:09 am

While I have not read your reference, but plan to, it seems that if a joint is not painful, then there are two ways you are brought to assess it: motion (increased or decreased) or by default (nothing else is working). The default position occurs in chronic pain patients or when the level of pain reduction or functional limitation is not acceptable to the patient...or maybe even the clinician. At that point a discussion should be undertaken so the patient knows you are trying something new.
If we arrive there because of motion, we are in trouble. The SIJ anatomically is highly irregular. See the work by Prassopoulos. In addition, the ability to detect motion or lack of motion at the SIJ is very poor. See many references.
However, this "silent hypomobility" concept may have some construct validity in an osteopathic sense. But we will be hard pressed to find any evidence supporting its use since the validity of the tools we use in its assessment are wrought with error.

8/29/2013 02:52:50 pm

Thank you for your comment Steve. We definitely recognize the limits in detecting mobility and alignment consistently and reliably in the SIJ, especially due to the lack of natural symmetry in the bones. However, just because the evidence has been weak thus far in the area does not necessarily mean the possibility should be eliminated. I think we would be fools to ignore all other impairments and instead focus on what we "think" we are seeing in the SIJ, regarding alignment and mobility. That being said, I think we should lean more towards the approach of "nothing else is working," except that we might instead decide to incorporate the treatment of the SIJ into our program in addition to the regular impairment-focused interventions of the rest of the body.

8/29/2013 04:44:04 pm

Studies show 4° of mobility for the SIJ which is hard to feel , you can test it not neccessary in motion but with compression, distraction or the P4 test, at this point if you find a reproduction of symptom you can go with motion assesment. However, i think the symptom is the key to incorporate it or not in the treatment.
Ps: Sorry for my english:)

9/2/2013 06:50:41 am

You are correct in that those listed tests are excellent for detecting pain coming from the SIJ, especially if clustered. However, what we are discussing here is when pain is not coming from the SIJ, but the SIJ's mobility impairments are contributing to the pain produced elsewhere. Again, you are correct in that there is little measurable motion in the SIJ, which is hard to detect. But the difference in detecting an intact ACL and a ruptured ACL is something like 3 mm. We are still able to appreciate the difference there. Obviously, the reliability for mobility testing of the SIJ is pretty low, but just because something has poor evidence does not mean we should completely eliminate the possibility from our minds. Instead we should be looking for ways to better those examination methods!

9/2/2013 11:50:57 am

Yes, but with a Lachman's you have or do not have an end point. I believe the tibial translation is also closer to 10mm.
The way you better the exam methods is to begin with case studies, then case series, then RCT's using a methodology, not trying to prove or disprove a specific test.
I believe this is often the case in manual therapy. We look for one technique to prove or assess something, rather than comparing a population via an RCT comparing the techniques and comparing the results.
One other thought. The SIJ moves may have some motion for some patients, and very little or no motion with others. We are much better off assessing thoracic and hip with a LBP patient.

9/2/2013 01:42:57 pm

The 3 mm I was referring to is with a difference between sides. And the point I was making about Lachman's was more along the lines of our ability to just detect movement. I absolutely agree that there are proper ways of evidence based practice to better our skills, what I meant was we should not simply rule something useless because of some evidence. For example, look at skills of the examiners in studies. And absolutely we want to look at hip, thoracic, and more for LBP patients. I was only indicating that we shouldn't exclude the SIJ.

Non-Painful SIJ Dysfunction

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