Q&A Time! How Do I Address SIJ Dysfunction? | Modern Manual Therapy Blog

Q&A Time! How Do I Address SIJ Dysfunction?


An OMPT Channel subscriber recently asked how I address SIJ dysfunction. I do not see this clinically too often, despite treating a decent amount of patients with lower back pain.

It is recommended that you rule out a lumbar condition first with a repeated motion exam. Most of the traditional tests we learn in school that involve palpation for position and motion of the SIJ are not reliable. I remember doing the Stork test/Gillet test 1 year after graduating and still having to pause and think about which movement of S2/PSIS meant what and what about the sacrum, etc.... I thought, when does this get easier? Seriously, abandon that test as it provides no useful clinical information.

  • Have the patient perform repeated flexion, extension, and sidegliding (first if unilateral complaints are present) one time to check for motion loss and/or symptom reproduction
  • Then take a baseline for their complaints including Sx location and intensity
  • have them perform each one of the above motions in standing and see how they affect Sx behavior
  • if the symptoms are affected either centralization, peripheralization, and/or remain better or worse, it is unlikely it is "only" SIJ dysfunction
  • if all repeated motions in standing and lying have no effect on complaints, progress to provocation testing
  • Note - I don't actually use Laslett's provocation tests, because I do not do ANY provocation tests and only assess movement and it's affect on complaints, but this is a well researched protocol for ruling in SIJ dysfunction
Since less than 10% of patients with lumbar pain meet the above criteria, I do not find myself treating patients with what would be diagnosed mechanically as SIJ dysfunction. However, it's not to say that if I see a patient with unilateral lumbar pain with a loss of SGIS to that side that I do not treat adjacent areas.

Using the SFMA you can easily find adjacent dysfunction in the thoracic spine, and hips (in the least). Many of the patients with the typical unilateral Sx presentation with no pain below the knee often have dysfunctional movement in the thoracic spine and the ipsilateral hip. This can cause excessive mobility in the lumbar spine and possibly pain. Working on those areas and restoring motion is my focus.

If a patient really does have stability issues in WB, such as late second trimester to 3rd trimester pregnancy, I do find that they respond very well to SI belts, but do not regularly prescribe them to patients who are not pregnant. An easy test is have them perform their provocation movement or position and belt them with a gait belt or velcro strap. If that helps, they may benefit from some stability offered by a belt. Many pregnant women find their pain actually improves when the baby finally moves. My wife and I used to be natural childbirth instructors and a quadruped position with upper body supported by forearms (upper body lower than lower) seems to help reposition babies. Also, quadruped cat/camels with focus on small repetitive lumbar rocking only (not thoracic) also helps relieve SIJ pain. I hope this answered your question! On Friday, I'll list 5 Useful Techniques for "SIJ" Dysfunction.

2 comments:

  1. Great post erson! Just a question though: if the pain low back patients presents with is typicalally not SIJ related, than how do we explain the studies that show almost complete pain resolution with anesthetic being injected directly into the joints themselves? I've read the research about the lack of movement at the joints, but I've clinically also seen some pretty good results with some people with SIJ "instability" being given prolotherapy to increase joint stiffness. What's the mechanism of action behind that?

    Thanks for the great read!!

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  2. That area is one of the few that has been shown in research to improve with prolotherapy. Most likely they do have a bit of instability, but it's been a while since I've reviewed that and not sure if other forms of Tx like MDT or manual therapy were tried. Prolo is one of my plan "C" that I refer to when other things are not working for LBP.

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