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.

[alophysio]

hi,

interesting point...however, some bold assertions are made in your post...like the majority of patients have a 'stuck' SIJ...

...in fact, in my experience, the majority of patients have poor motor control. There are very few "stuck SIJs" out there i am afraid - but i do come across them from time to time.

The sympoms of a stuck SIJ in my opinion are:

1. inability to bear weight on the affected side IF the joint is stuck (fixated) in a "subluxed" position (for want of better terms!) - if is it stuck as in fused or fibrosed etc, it might actually be in a closed pack position in which case it will bear weight just fine thank you very much.

2. SIJ joint glide testing will reveal the affected SIJ WILL NOT move in the primary direction it is fixated in and may or may not move in the other direction - the SIJ has 2 arms to the joint - it is "j-shaped". And on a sidebar, most people do their SIJ joint testing with WAY TOO MUCH FORCE - the joint moves only a few degrees and a few mm in gliding - try to remember that.

3. on ASLR, a fixated joint may respond WORSE to compressions - either manually or with a belt because the joint is usually painful

4. on stork testing, the PSIS and S2 will not move relative to one another no matter what you do - true fixated joint is just that - doesn't move.

_____

i am presuming you might be an author of this 'new research' - i think what you will need to do is highlight the fact that most problems are motor control driven and that physios have been using misnomers to describe what they are seeing.

Why treatment for a "fixated joint" or "stuck SIJ" or any joint for that matter works (when the real problem is motor control) is because the manipulation/manual therapy often gives a neurophysiological effect and causes some relaxation of the gripping global muscles. Then once that is done, you can do the local muscle stabilisation - which will address the real motor control problem anyway. Therefore, the therapist has now reinforced their belief that they got the diagnosis right...when it was technically wrong - BUT the patient got better so what is the concern?? I personally prefer to be technically and practically correct!!

As for your APAS, i have found your entry here...Asymmetric pelvic angle syndroms, APAS - Injury Update Forum. What you describe is certainly not new my friend but kudos to you for working it out on your own...BTW, a syndrome is what you call something when you don't know why it is happening - in other words, in the absence of a definition/diagnosis. I have the diagnosis for you...Motor Control Dysfunction. Read Diane Lee's textbook on the The Pelvic Girdle 3rd edition and don't forget to include that reference in your research paper...otherwise you are ignoring a major player in pelvis treatment!!

As for your research, you assert that you had 100% false positive on stork test using your ABD test. A problem might be your sample size. Another problem might be palpation error - there is enough research to suggest that the stance phase of stork is reliable but not sure about the swing/hip flexion phase which is where your test would fall. You may want to do your research overseas where they use RSA and XRay to determine true bony movements.

If you are interested in letting me read your findings, please feel to email or PM me.

I hope what i have written helps...

Cheers

[Canuck Physio]

hmm... raises questions as to muscular slings and muscle patterning

[neuromuscular]

Originally Posted by Canuck Physio

hmm... raises questions as to muscular slings and muscle patterning

Thank you.

You are right.

The test to prove this is as follows:

Landmarkws: ASIS to ASIS, PSIS to PSIS, ASIS to PSIS (R&L).

From standing closed leg position have the patient do hip abduction for each landmarking at 15 cm foot positions to the maximum for the patient.

The following statistics have been obtained:

Patients with no back pain: Pelvic angles near anatomical neutral throughout test range.

Back Pain:

Only 10% have bilaterally equal pelvic angles either in anterior or posterior rotation.

90% have differing pelvic angles or angles which increase in difference as the hip abduction proceeds.

60% have right anterior left posterior
20% have right anterior left neutral
20% have right in greater rotation than left.

See what your statistics are.

This was in over 1,000 patients.

A true stuck SI joint was not seen.

Best regards,

Neuromuscular.

[neuromuscular]

Originally Posted by alophysio

hi,

interesting point...however, some bold assertions are made in your post...like the majority of patients have a 'stuck' SIJ...

...in fact, in my experience, the majority of patients have poor motor control. There are very few "stuck SIJs" out there i am afraid - but i do come across them from time to time.

The sympoms of a stuck SIJ in my opinion are:

1. inability to bear weight on the affected side IF the joint is stuck (fixated) in a "subluxed" position (for want of better terms!) - if is it stuck as in fused or fibrosed etc, it might actually be in a closed pack position in which case it will bear weight just fine thank you very much.

2. SIJ joint glide testing will reveal the affected SIJ WILL NOT move in the primary direction it is fixated in and may or may not move in the other direction - the SIJ has 2 arms to the joint - it is "j-shaped". And on a sidebar, most people do their SIJ joint testing with WAY TOO MUCH FORCE - the joint moves only a few degrees and a few mm in gliding - try to remember that.

3. on ASLR, a fixated joint may respond WORSE to compressions - either manually or with a belt because the joint is usually painful

4. on stork testing, the PSIS and S2 will not move relative to one another no matter what you do - true fixated joint is just that - doesn't move.

_____

i am presuming you might be an author of this 'new research' - i think what you will need to do is highlight the fact that most problems are motor control driven and that physios have been using misnomers to describe what they are seeing.

Why treatment for a "fixated joint" or "stuck SIJ" or any joint for that matter works (when the real problem is motor control) is because the manipulation/manual therapy often gives a neurophysiological effect and causes some relaxation of the gripping global muscles. Then once that is done, you can do the local muscle stabilisation - which will address the real motor control problem anyway. Therefore, the therapist has now reinforced their belief that they got the diagnosis right...when it was technically wrong - BUT the patient got better so what is the concern?? I personally prefer to be technically and practically correct!!

As for your APAS, i have found your entry here...Asymmetric pelvic angle syndroms, APAS - Injury Update Forum. What you describe is certainly not new my friend but kudos to you for working it out on your own...BTW, a syndrome is what you call something when you don't know why it is happening - in other words, in the absence of a definition/diagnosis. I have the diagnosis for you...Motor Control Dysfunction. Read Diane Lee's textbook on the The Pelvic Girdle 3rd edition and don't forget to include that reference in your research paper...otherwise you are ignoring a major player in pelvis treatment!!

As for your research, you assert that you had 100% false positive on stork test using your ABD test. A problem might be your sample size. Another problem might be palpation error - there is enough research to suggest that the stance phase of stork is reliable but not sure about the swing/hip flexion phase which is where your test would fall. You may want to do your research overseas where they use RSA and XRay to determine true bony movements.

If you are interested in letting me read your findings, please feel to email or PM me.

I hope what i have written helps...

Cheers

The problem is not a motor problem per sae.

The problem is a guarding response or a neuromuscular holding pattern.

I have talked to Diane Lee and Andry Vleeming and I do not find any test of the SI joint as giving anything but 100% false positives.

The person doing the research is associated with a USA institute. His research is confirnming my assessment as accurate and giving a much higher success rate than previous theories. The resistant type and active type of testing do not address the main problems. The singular most accurate test and the most objective is the postural type of tests. Any other test has a subjective element.

The person doing the research will be publishing a research paper as his docturate. An international magazine has shown much interest in it. Further, as the editor states, many will find it a theory hard to accept as it runs counter to many theories.

However, success rates are low for treatment of low back pain, regardless of the methods used including that of Diane Lee, et al. See BMJ series by Helen Froost in 2004 and later in 2006, Archive of Internal Medicine September 24, 2007, Dr. Hamilton Hall of Canada in a lecture in U of Alberta November 12, 2004, ETC., ETC., ETC., ETC.,..... The success rate using this treatment protocol is over 90% unlike the 27.5% obtained in the Archive of Internal medicine. The proof will be in the pudding.

I have no problem with people challenging the theory and therapy, but first try the tests. Other wise it is just being closed minded.

Best regards,

Neuromuscular.

[neuromuscular]

This concept will be hard for many as no research has been into pelvic angles.

Even the eminent work MOVEMENT STABILITY AND LOW BACK PAIN THE ESSENTIAL ROLE OF THE PELVIS did not have one contributor that mentioned pelvic angles. Neither were the adductors even mentioned in this work.

However, when the four sided test using the pelvic landmarks is done with hip abduction, the difference of pelvic angles becomes very pronounced such that even a novice can see the change. Angles move from 5 degrees to over 30 degrees in many. The problem has been that any postural assessment has been done at only anatomical neutral. The hip abduction is necessary to cause a specific stress to the pelvic area. Most resistance and movement testing has a very substantial subjective component. This test is pure objective facts about the patient's true condition.


I invite all to try the test of landmarks ASIS to ASIS, PSIS to PSIS, and ASIS to PSIS (R&L) with hip abduction directly lateal in the coronal plane at 15 cm increments. For most it will present new and perplexing information.

Therapy is affected. Present success rates for low back pain are dismal as several sources show. This assessment leads to therapy with a success rate in the order of over 90% in reducing pain by 90%. That may seem like a grand claim, but the research facility doing the follow up in Nebraska, USA is having equally successful results.

Further, the therapy does not trick the body to accept an abnormal position as normal, but returns the innominate bones and subsequently the other postural components to anatomical neutral.

I urge all to try the test with hip abduction. You will be impressed by the new data obtained.

Please send your feedback in once you have tried the test.

Best regareds,

Neuromuscular

[alophysio]

Hi,

1. Speaking for myself, I am certainly open minded...in doing so though, i must be thorough and critically evaluating what you propose...

2. Can you see that by making such a definite statement such as "there is no such thing as a stuck SIJ" can be seen as closed-minded??

3. Motor control includes overactivity and neural patterning my friend - we might be disagreeing on terms here...

4. you mention the landmarks as ASIS to ASIS, PSIS to PSIS and ASIS to PSIS...If you are determining if the SIJ is stuck or not, then shouldn't you have a landmark on the sacrum itself??? One side of the joint will not be able to detect movement.

5. I am sorry for not understanding but can you explain what are the angles you are measuring - how are they formed? What planes are you measuring in?

6. You say measure hip ABD at 15cm foot positions - the leg moves in an arc. Also, different leg lengths will mean 15cm will be a different ABD angles for different people...do you mean 15degree increments? That would make more sense - angular kinematics vs linear kinematics.

7. If only ilial measurements were used, then i am unclear as to how you can ascertain what the problem/dysfunction is...

...back pain patients might have asymmetrical angles but htat could be from L5/S1, SIJ, Pubic Symph, and hip dysfunctions. From what i can deduce from the limited amount of information you have provided is that there is a dysfunction somewhere.

8. i will look up the references when i can.

9. i would like to compare my results of doing the test but i would like clearer methods and how to calculate the results...e.g. what do you mean by saying the majority have right ant rot, left post rotation - what is "anatomical neutral", etc etc.

10. From what i can concluded, the hip ABD test is testing whether or not you have pelvic-hip dissociation with contralateral hip stability. In other words, testing the client's motor control ability to maintain a stable pelvis whilst using an open chain movement.

11. From the post above this one, if there is no research done on pelvic angles, how would one use it and write it in an "eminent work".

12. if you use only the ASIS and PSIS in whatever combinations, the result is called "intra-pelvic torsion" (IPT) (as outlined by Diane and LJ Lee)...e.g. left ASIS and PSIS showing post rot and the right ASIS and PSIS showing ant rot = left IPT. It just tells you that the pelvis in not in neutral.

13. What is the therapy that is used to produce such wonderful results? Can you give a case study from over 1000 patients that you have seen?

14. Can you PM me the author of the research/PhD or his/her email or some other way of finding out what the method is please?

Thanks...your responses to the above would be very helpful.

[neuromuscular]

Thank you for your continued interest.

I have found that most people with the exlusion of Ola Grimsby and possible Dr. Robert ELlis have difficulty with this concept. I have talked to or had communication with Andry Vleeming & Diane Lee. Both of which had some trouble with the concept. One was very closed to any orthopeadic testing or landmark testing.

I agree that we must be critical and not accept something just because someone sayes it is so.

I did mention a test of the PSIS to sacrum with hip abduction. This shows that the PSIS moves away from the sacrum with hip abduction, but moves with the sacrum with torso flexion and hip flexion. This disproves the first as inaccurate. It was used to disprove other so called SIJ tests. The original standing SIJ test and others is an illusion that has caused many to pursue the illusive problematic SIJ.

I agree that the statement of no stuck SIJ does sound close minded, but it was said to get attention and it is said with the evidence in over 1,000 patients. Further, it does not preclude tramatic injury where the joint is crushed or damaged, but does say that there is no such thing as a stuck SIJ in most patients as we commonly hear in books like ORTHHOPEADIC PHYSICAL ASSESSMENT by David Magee U of A to name just one of many. This is more commonly believed that one would like to see.


Motor contrl to me is the signal controlling the muascle as differentiated from the other control factors which affect the signal. For example, we study about muscle spindle, but who has studied the "calibration" of the muscle spindle or golgi tendoon organ. Can these ge recalibrated to a different setting or set point from normal? I have not seen any information or research onthis. Neither has any one that i mentioned this to.

The angles are from the horizontal plane. If you do the test you will note that either the PSIS moves inferior to the ASIS or the ASIS moves inferior to the PSIS. It is obvious. You may measure the angles or the distance that the PSIS or ASIS moves inferior to the other. You will not have to guess as the movement with hip abduction in most is very pronounced as hip abdcuction proceeds. The movement is from the horizontal plane. I used the PSIS as the level of the horizontal plane, but you may choose to do as you see fit.

The test must be full weight bearing as the postural control muscles cause the distortion. Therefore, a floor measure was used. Since I am still familiar with the foot and inches I used the equivalent of 6 inches or 15 cm for the initial test. I now use the one foot increment as I have become familiar with the test and know what I am looking for. Distortion increases most after 75 cm. It does not matter which kinetics you use as the distortion is with distance and the measure is only for a coomon reference.

The problem or dyfunction is evident from the distortion of the innominate bones. Once you use the test you will see the data that has been missed. The anterior pelvic angle on the right is from a contralateral cause. This causes a correction by the proprioceptive sense to keep the eyes in line with the feet and the distortion progresses.

Anatomical neutral as published and as I have seen, is when the ASIS and PSIS are level in the horizontal plane. The PSIS should not be inferior to the ASIS or to the other PSIS. The same is true of the ASIS.

I find that any test of motor ability has a very substantial subjective factor. I use the postural assessment first. It is most objective and provides the most objective data. It is much like the resisted tests of the Muscle Testing manual by Kendall. They are of some use, but there are too many subjective factors - even when an instrument replaces the human factor.

The reason that pelvic angles were not in the eminant work, which was research papers, is that none of the participating papers or the editor considered pelvic angles of any concern. There were extensive research papers on the SIJ but not one o the authors considered the pelvic angles or innominate bone position.

The therapy is direct pressure into the muscle at 90 degrees to the muscle body. the distortion is the indicator of the muscular problem.

Thank you again. Best regards.

[estherderu]

dear everybody,

the discussion about the SI joint being able to move/not move get stuck/ or not, has been around as long as I have been a physio. I did train as a OMT with Cyriax and Kalternborn.... at the time, so you could say I have some extra education in this field.
I am, however, not going to react in detail to this Y/N discussion but with a little practical idea of mine.

Because I have always found spinal + SI mobilisation/manipulation physically strenuous and an extremely passive way of treating patients I optrd for a more active approach.
Whatever the real reason, stuck or not stuck, we will find asymmetric movement patterns and strenght differences in these patients.
One of the most efficient ways of dealing with this is, in my opinion, using the PNF trunk patterns. I can really recommend them to everybody.
If you never learnt them, ( most college´s + UNI´s only teach you the arm and leg patterns) you can go to the PNF website for the names of people who have followed the "official course(s). IPNFA

Why tell you?, because even without always knowing (Y/N stuck SI), using these techniques has helped me help many people get rid of their symptoms and pain.


Esther
Good luck with your discussion. I do find it very interesting but will leave that up to you.

[neuromuscular]

[quote=estherderu;23438]dear everybody,

the discussion about the SI joint being able to move/not move get stuck/ or not, has been around as long as I have been a physio. I did train as a OMT with Cyriax and Kalternborn.... at the time, so you could say I have some extra education in this field.
I am, however, not going to react in detail to this Y/N discussion but with a little practical idea of mine.

Because I have always found spinal + SI mobilisation/manipulation physically strenuous and an extremely passive way of treating patients I optrd for a more active approach.
Whatever the real reason, stuck or not stuck, we will find asymmetric movement patterns and strenght differences in these patients.
One of the most efficient ways of dealing with this is, in my opinion, using the PNF trunk patterns. I can really recommend them to everybody.




Thank you.

I agree that one hundred years of believing the the SIJ is the problem is too long. Try the test for APAS. You will find the data obtained of interest.

The problem with doing what we feel will make the patient better or makes the nociceptors " recalibrate " to allow for an abnormal condition is that we may not have made the patient's condtiion actually better.

We need an objective, reliable, accurate guage of how the patient is progressing.

I feel that in the low back or pelvic treatment the four sided assessment using the ASIS and PSIS landmarks gives us a benchmark for deciding if what we did actually improved the patient's condition by returning them to a more anatomical neutral.
I have been to several seminars where after the "therapy" the patient felt "better" and the ego of the therapist was pacified, but there was no difference in the pelvic position. So did they like the manipulative therapy that opens and closes joints but does more to reset the nociceptors to an atrificial normal than normalize the postural position of the patient to anatomical neutral.

The PSIS to sacrum with hip abduction will disprove the SIJ dysfunction "posivite" and is a guage of the joint better than the present "standards".

The SIJ is not stuck, but present direction is stuck in testing it. Try the APAS test on your patients to see if there is a change after your theraputic intervention. Please give me feedback.

Best regards,

Neuromuscular.

[neuromuscular]

Please focus on the major thrust of the discussion:

SIJ testing is misleading us from the bigger picture of the differing of pelvic angles.
There is little on how differing of pelvic angles affects therapy.

Best regards,

Neuromuscular

[Physio Dace]

Ahh the old "super pelvic alignment wit hhip abduction" test for LBP patients rears its head in yet another discussion thread. Sorry Neuroman but from the above discussion Alophysio has the better of the argument - your statements regarding this test are extremely rigid and possibly inflammatory - but good on you for pushing our buttons. Science wouldn't be science without critical anlaysis and arguments. I look forward to reading another plethora of threads on this topic......and perhaps some quality populational correlation studies to support your extremely high incidence rates. Oh and some biomechanical/motor control/neurophysiological etc theories to support why such malignments exist in LBP (you know cause/effect/chanceetc) would also be welcomed.

Onward soldiers....

[neuromuscular]

Originally Posted by Physio Dace

Ahh the old "super pelvic alignment wit hhip abduction" test for LBP patients rears its head in yet another discussion thread. Sorry Neuroman but from the above discussion Alophysio has the better of the argument - your statements regarding this test are extremely rigid and possibly inflammatory - but good on you for pushing our buttons. Science wouldn't be science without critical anlaysis and arguments. I look forward to reading another plethora of threads on this topic......and perhaps some quality populational correlation studies to support your extremely high incidence rates. Oh and some biomechanical/motor control/neurophysiological etc theories to support why such malignments exist in LBP (you know cause/effect/chanceetc) would also be welcomed.

Onward soldiers....

This reply is like many who do not consider a difference of view point from the "normal". It is unfortunate that some will not try a test on its own merit, but just put it down because it is different.

The reserach abstract is scheduled for year end. The research is by another person in Lincoln Nebraska USA. It has confirmed that there are numberous flaws in the present SIJ dysfunction model.

I hope that it will be considered with less disdain at that time.

Best regards,

Neuromuscular