Q&A Time! Sacroiliac Joint vs Lumbar | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Q&A Time! Sacroiliac Joint vs Lumbar

Today's Q&A Time is regarding an often asked question regarding SIJ vs lumbar assessment and treatment sequencing. It's a very good question, even if the pseudo science behind "SIJ" assessment and treatment is not.

Blame the osteopaths with their overly complex right on right, left on right, unilateral flexion/extension, upslips, downslips, METs etc... and the influence they've had on countless of orthopaedic PTs and PT instructors. Trust me, this stuff absolutely does not have to be this complex.

What used to go on in my head after fellowship

  • pt comes in with unilateral LBP, around the SIJ not below the knee
    • differential - could be disc, could be SIJ, could be facet, could be muscle imbalance
    • it's not below the knee, and it's unilateral, rule out SI?
    • supine to long sit - never "sat" well with me
    • look at PSIS, S2, levels - hated this
    • do the stupid stork/Gilet test - this always made me feel dumb
    • palpate all over the place - you get the hang of this after a while
    • try to rationalize it in your head that something is moving earlier, something else is higher or deeper or some other such you have to palpate it 1000 times to feel it (which is really just believing it)
    • then look at lumbar PIVM
      • believe that you can tell which vertebrae you're on, not to mention feeling whether or not something is gapping or approximating
    • after perhaps 10-15 minutes palpation and passive assessment, excuse yourself politely while you figure out what to do
    • it's no wonder the SIJ and palpation tests have some of the worth reliability in the history of special tests

What goes through my head now

  • pt comes in with unilateral LBP, around the SIJ not below the knee
    • what do they "have?" - low back pain
    • is pain intermittent? --> most likely lumbar rapid responder
    • check lumbar repeated motion for asymmetries and directional preference
    • if too painful to move repeatedly in WB, move to NWB
    • if too painful to move in NWB, try positioning in what you think will be the directional preference
      • for unilateral complaints - try prone modified hips offset position as in this post
      • lumbar rotation in flexion, loading (closing) the involved side in sidelying (painful side on the table)
    • go heavy on the pain science education, decrease fear avoidance
    • use OMPT techniques - IASTM, DN, Joint mob, manip, neurodynamics, functional mobilization, to get them to be able to move
    • instruct them how to do hopefully a WB repeated loading strategy by the time they leave, if not, they may have to take off of work if acute and do NWB loading strategies for 1-2 days
  • after putting out the fire, use the SFMA to look for other head to toe asymmetries in movement and motor control, clean those up
As you can see, the more modern way of forgetting about SI, IS, AF, FA, positional faults, intervertebral motion, stabilization, etc, is much easier. On the occasion that repeated motions are ruled out, thoracic and hip motions are also symmetrical and normal, and they patient is a very lax female, possibly either a dancer/gymnast younger than 18 yo or pregnant or recently pregnant, they may need some stabilization. An SI stabilization belt works best to calm down the peripheral sensitizaiton as well as stabilization exercises or those for motor control as needed.

I hope this answered your question. You are struggling at the point where I was were you were given TOO MUCH INFORMATION. A simple and thus more reliable and systematic way of assessment that dictates treatment is needed for not only the lumbar spine but any area. Once you let go of pathoanatomy and look at movement and pain science education it is very liberating, but it can be a tough change. 

In summary
  1. eliminate the threat
    • pain science education
    • repeated motions exam for directional preference or position of relief
    • OMPT to get them moving
    • HEP keeps them better
  2. use a system like the SFMA to clear the movement
    • clear up asymmetries in motor control to help prevent future injury
    • get their capacity up to speed - ROM and pain free sometimes not enough to prevent recurrence
Keeping it Eclectic...

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