WHATS THE EVIDENCE ON SIJ ASSESSMENTS
Within the therapy world the assessment and treatment of the Sacroiliac Joint, or the 'SIJ' as its more commonly known, is a fiercely debated area that often creates lively disagreements, as I recently found out when I posted a comment on Twitter a while ago stating I was surprised that many still use unreliable palpation tests to assess it. After some much RSI inducing tweeting, which ended up with one tweeter calling me a 'critical arsehole' I thought I would write a piece on what my experience and more importantly what the research is telling us about assessing the Sacroiliac Joint.
For me as physio the SIJ has always been one of those areas I never did fully understand when I was a student many years ago. I can recall being in classes being confused as hell listening to tutors explaining the arthro-kinematics of it during movement, and how alterations to these movements can cause pain and dysfunction.
And it got even worse in the practical lessons with being even more confused as a tutor would tell me to press one of my class mates pelvis and say...
"can you feel that counter nutation of the sacrum"
"do you feel that blocked left sided innominate"
"Err.... no I can't...." i'd reply sheepishly with a bemused look on my face!
All I felt during these practicals was an idiot, not SIJ movements. I just could not feel much moving anywhere at any time on anyone. Yet, everyone else in my class seemed to be able to, so I kept prodding and poking to see if I could improve my feel, daring not question the absurdity of trying to feel tiny, small, subtle movements through layers of thick dense tissue.
I kept telling myself you're just new at this, you needed to develop your palpation skills, especially as so many other physios kept telling me that they could feel if the SIJ was moving too much or not enough. So I persevered and every opportunity I got, I pressed, poked, and prodded peoples SIJs, as I really did want to get better at this.
But I didn't get any better! And I still couldn't feel anything after years of practice!
MORE PRACTICE NEEDED?
So I thought I needed some more training, so as a junior physio I went on a very well known SIJ post graduate course with a very well known international pelvic specialist hoping this would make me a much better SIJ assessor.
It didn't.
Instead, I was just more confused, more frustrated, and a lot poorer as this course cost me a small fortune as a junior physio. After this course I now had to deal with identifying 6 planes of SIJ movement including rotational and twisting movements, and other weird sounding stuff like flares and upslips that I was supposed to be able to detect.
I spent two days with this 'expert' pretending I was a sacrum with my arms up out to the side twisting this way and that, as well as pressing a lot of backsides (some nicer than others) listening to my class mates shouts of joy when they suddenly felt an anteriorly rotated innominate, or gasps of amazement when an upslip was found on a model, it was like being back at Uni all over again, only worse as I was now qualified and still telling people I couldn't feel fuck all.
Again all I could feel was skin and some bony stuff not moving much anywhere significantly, but now also had a much ore sceptical feeling about this SIJ stuff... What was going on? Why couldn't I feel this stuff, yet others could?
Was I just a leather fingered, ham fisted numpty? Or where the others delusional or wishful thinkers?
CAN WE PALPATE THE SIJ?
So I started to dig a bit further into the evidence and found that there is actually quite a lot of good evidence that palpation tests of the SIJ are extremely unreliable and show poor inter-tester reliability, that was never discussed at uni or on this course.
For example, Holmgren and Waling showed that four most common static tests used to detect asymmetry of the SIJ is of "doubtful utility"
A study by McGrath questions the ability to detect the commonly used bony landmarks of the SIJ stating "the continued use of manual diagnostic palpation as a basis for manipulative intervention is questionable".
And a study by Preece et al highlights the vast anatomical differences that there are in the human pelvis and that variations in pelvic morphology "may significantly influence measures of pelvic tilt and innominate asymmetry"
These papers, and many others, show that feeling for SIJs movement is not reliable and not going to give any useful information about the SIJ positioning or pathology .
Although we know that the SIJ is a part synovial joint and it does moves, it doesn't move much. It moves only a few degrees, totalling just a few millimetres of actual movement. Goode et al showed at maximum the SIJ moves about 8mm in some, but realistically its much less than this with average being around 2-3mm.
Studies by Freburger et al and Riddle et al have looked at the reliability of commonly used movement assessment tests for SIJ movement, such the Stork and Gillet's tests, both showing poor inter tester reliability, low sensitivity, and poor specificity. And another by Robinson et al confirms the finding of the other two studies, basically telling us that we just can NOT reliably feel the SIJ move or not.
So if we combine very small joint movements, underneath lots of layers of thick connective tissue, with poor palpation reliability, specificity and sensitivity I hope you can realise that feeling for a SIJ's movement is about as plausible as feeling for electrical wires through plasterboard walls.
However, despite this the techniques are still being taught and still very popular with many claiming they can detect these SIJ movements despite the evidence saying otherwise. Why?
Well first I think its some desperately trying to hang onto something they have invested a lot of time and training into, as well as some dogmatic clinicians just defending their beliefs to prevent them looking or feeling silly and gullible. I also think this belief in palpation skills gives some therapists a sensation skill, expertise and control over a very uncertain area.
SO HOW CAN WE ASSESS THE SIJ?
So where does this leave us therapists (and the patients who may also be reading this as well) when we do suspect the SIJ maybe a source of pain, how can we reliably assess it if we cant trust palpation?
Well there are some tests we could do, that doesn't involve trying to palpate microscopic movements. These tests have been found to be more reliable and sensitive in determining IF an SIJ is causing pain rather than trying to determine if its moving too much or too little, or twisted this way or that, which doesn't really matter if its not causing any pain.
First is perhaps starting by using the location of pain, Van der Wurf et al showed that you can 'possibly' start to suspect an SIJ issue if the pain is located in whats called the 'Fortin' area but NOT in the 'Tuber' area see below image.
However, you can't just use the location of the pain alone, we need other tests to confirm the SIJ is an issue. Laslett et al paper along with another by Van der Wurf et al shows that there isn't one stand alone test but rather a combination of tests, and if 3 or more are positive then there is a 79% specificity for the SIJ to the source.
These tests are
- Gaenslen torque test
- FABER's (Patricks Test)
- Femoral shear test
- ASIS distraction test
- Sacral thrust test
Video demonstrations of these tests can be seen on this Youtube site.
I would also add to this list the Active Straight Leg Raise or ASLR test which has also been found to be validated to highlight pain from the posterior pelvic area here although there are some issues with this test.
SUMMARY
So I hope you can see that trying to assess a SIJ by its position and movement or lack there of, using palpation tests will not gain you any useful or relevant information. In fact it can lead you down the wrong road of completely. Just because you think an SIJ is slightly this way or that compared to a so called 'normal' SIJ (whatever that is) doesn't mean its a source of someones pain, and that goes for any joint/posture!
If you are a therapist that still uses palpation tests to assess the SIJ you need to question your reasons for doing this and look at what the evidence shows, and STOP.
If you are a patient with a suspected SIJ issue and you have a therapist palpate your SIJ claiming they can feel it move too much or too little I would suggest you question them, or just walk away.
Now I'm sure this blog will create some mixed feelings and comments as it did last time I mentioned it, so please feel free to comment. As for the person who called me a critical arsehole, thank you, your are very very right!
Adam
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