Regarding Sacroiliac Article ADVANCE October 29, 2012.
Dear Editor,
I have a few comments that were motivated by the article on SI Joint Pain titled Finding the Perfect Fit: Therapist learns through personal experience how to identify SI joint pain. The author insightfully reports that SIJ symptoms can be overlooked in clients with total hip and total knee replacements, who experience asymmetry of weight bearing. I agree that there is a common faulty pelvic pattern in this population consisting of left or right pelvic side-glide fixation. While this may have served them well in decreasing weight-bearing on the painful side pre-op, it idealy would be addressed in post op rehab. This pattern is sometimes obvious visually, other times it is subtle and can only be found with passive testing. Unfortunately, at times this specific pattern is perhaps neglected, such that long after rehab, patients are observed with the
pelvis shifted to one side, still requiring an assistive device. This pattern can be readily corrected or significantly improved with prolonged passive pelvic glide over a fulcrum.
The author insightfully encourages referral to pelvic floor specialists such as for peri-partum SIJ conditions and advocates addressing the trunk, hip and pelvic musculature for strengthening and restoration of normative movement.
I respectfully disagree with the author’s statement that lax ligaments will always be lax. While sometimes true, the pelvic ligaments have extensive muscular attachments, directly, or indirectly via fascial expansions as is detailed in the literature, including the 2012 book titled Fascia (Elsevier). Muscle function can be inhibited via the Type III and IV mechanoreceptors when a ligament has excessive tension, compression or chemical irritation. Ligaments can respond to alterations in muscle length/tension. Fortunately, the long dorsal SI, sacrotuberous and sacrospinous ligaments are readily accessible for palpation and discerning changes in tone in response to intervention. It is important to discern if the laxity is mutable.
There is a pervasive belief that malalignment of the pelvis is caused by malalignment within the SIJ. Quite often it is simply due to the unique biomechanics of the entire pelvis moving asymmetrically, in which the SIJ’s are loaded and function as a stable clutch. Soft tissue overlying the lumbopelvic region deforms asymmetrically and gets over-interpreted. Sturesson et al have done detailed studies that undergird this statement, and others have addressed the semantic and clinical problems of sacroiliac “joint” dysfunction. A detailed exploration of these concepts can be found in a very recent book chapter title Sacral Torsion: A New Approach To an Old Problem, in the book Dynamic Body. The topic of SIJ dysfunction is controversial, yet the paradigm is slowly changes as research continues to provide guidance.
Thank you very much.
Jerry Hesch, MHS, PT
Hesch Institute
Henderson, NV
USA
REFERENCES
Cook C, Massa L, Harm-Ernandes I, et al. (2007). Inter-rater reliability and diagnostic accuracy of pelvic girdle pain classification. J Manip Physiol Ther., 30:252-8.
Egund N, Olsson TH, Schmid H, et al. (1978). Movements in the sacroiliac joints demonstrated with roentgen stereophotogrammetry. Acta Radiol Diagnosis, 19:833-846.
Goode A, Hegedus EJ, Sizer P, et al. (2008). Three Dimensional Movements of the Sacroiliac Joints: A Systematic Review of the Literature and Assessment of Clinical Utility. J Man Manip Ther., 16(1):25-38.
Hesch J. (1996). Evaluating sacroiliac joint play with spring tests
Hesch J. (1997). Evaluation and treatment of the most common pattern of sacroiliac joint dysfunction. In: Movement, Stability & Low Back Pain: The Essential Role of the Pelvis. Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R, eds. London, United Kingdom: Churchill Livingstone, 535-552.
Hesch J, Aisenbrey J, Guarino J. (June 25, 1990). The Pitfalls Associated With Traditional Evaluation of Sacroiliac Dysfunction and Their Proposed Solution. Presented at Annual Conference of the American Physical Therapy Association, Anaheim, Ca.
Huijbregts P. (May/June 2004). Sacroiliac joint dysfunction: evidence-based diagnosis. Feature Article of the Orthopedic Division Canadian Physical Therapy Association,
18-44.
Huijbregts P. (2008). Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther., 16(3):153–154.
Janiak DD. (2001). Review of sacral somatic dysfunction. AAO, 18-23.
Jordan Theodore R. (2006). Conceptual and treatment models in osteopathy II. Sacroiliac mechanics revisited. AAOJ, 11-17.
Levangie PK, Norkin CC. (2005). The hip complex. In: Joint Structure & Function: A
Comprehensive Analysis. Philadelphia, PA:F.A. Davis, 368-372.
Neumann D. (2002). Axial skeleton: osteology and arthrology. In: Kinesiology of the
Musculoskeletal System. St Louis, MO. Mosby Inc., 303-305.
Sakamoto N, Yamashita T, Takebayashi T, et al. (2001). An Electrophysiologic Study of Mechanoreceptors in the Sacroiliac Joint and Adjacent Tissues. Spine, 26(20):68-71.
Sturesson B, Selvik G, Uden A. (1989). Movements of the sacroiliac joints: a roentgen
stereophotogrammetric analysis. Spine, 14:162-165.
Sturesson B, Uden A, Vleeming A. (2000). A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine, 1;25(3):364-8.
Tullberg T, Blomberg S, Branth B, et al. (1998). Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine, 15;23(10):1124-8; Discussion 1129.Wyke B.D. (1972). Articular neurology: a review. Physiother.,
58:94.
Walker JM. (1992). The SacroiliacJoint: A Critical Review. Phys Ther., 72(12):913.
Dear Editor,
I have a few comments that were motivated by the article on SI Joint Pain titled Finding the Perfect Fit: Therapist learns through personal experience how to identify SI joint pain. The author insightfully reports that SIJ symptoms can be overlooked in clients with total hip and total knee replacements, who experience asymmetry of weight bearing. I agree that there is a common faulty pelvic pattern in this population consisting of left or right pelvic side-glide fixation. While this may have served them well in decreasing weight-bearing on the painful side pre-op, it idealy would be addressed in post op rehab. This pattern is sometimes obvious visually, other times it is subtle and can only be found with passive testing. Unfortunately, at times this specific pattern is perhaps neglected, such that long after rehab, patients are observed with the
pelvis shifted to one side, still requiring an assistive device. This pattern can be readily corrected or significantly improved with prolonged passive pelvic glide over a fulcrum.
The author insightfully encourages referral to pelvic floor specialists such as for peri-partum SIJ conditions and advocates addressing the trunk, hip and pelvic musculature for strengthening and restoration of normative movement.
I respectfully disagree with the author’s statement that lax ligaments will always be lax. While sometimes true, the pelvic ligaments have extensive muscular attachments, directly, or indirectly via fascial expansions as is detailed in the literature, including the 2012 book titled Fascia (Elsevier). Muscle function can be inhibited via the Type III and IV mechanoreceptors when a ligament has excessive tension, compression or chemical irritation. Ligaments can respond to alterations in muscle length/tension. Fortunately, the long dorsal SI, sacrotuberous and sacrospinous ligaments are readily accessible for palpation and discerning changes in tone in response to intervention. It is important to discern if the laxity is mutable.
There is a pervasive belief that malalignment of the pelvis is caused by malalignment within the SIJ. Quite often it is simply due to the unique biomechanics of the entire pelvis moving asymmetrically, in which the SIJ’s are loaded and function as a stable clutch. Soft tissue overlying the lumbopelvic region deforms asymmetrically and gets over-interpreted. Sturesson et al have done detailed studies that undergird this statement, and others have addressed the semantic and clinical problems of sacroiliac “joint” dysfunction. A detailed exploration of these concepts can be found in a very recent book chapter title Sacral Torsion: A New Approach To an Old Problem, in the book Dynamic Body. The topic of SIJ dysfunction is controversial, yet the paradigm is slowly changes as research continues to provide guidance.
Thank you very much.
Jerry Hesch, MHS, PT
Hesch Institute
Henderson, NV
USA
REFERENCES
Cook C, Massa L, Harm-Ernandes I, et al. (2007). Inter-rater reliability and diagnostic accuracy of pelvic girdle pain classification. J Manip Physiol Ther., 30:252-8.
Egund N, Olsson TH, Schmid H, et al. (1978). Movements in the sacroiliac joints demonstrated with roentgen stereophotogrammetry. Acta Radiol Diagnosis, 19:833-846.
Goode A, Hegedus EJ, Sizer P, et al. (2008). Three Dimensional Movements of the Sacroiliac Joints: A Systematic Review of the Literature and Assessment of Clinical Utility. J Man Manip Ther., 16(1):25-38.
Hesch J. (1996). Evaluating sacroiliac joint play with spring tests
Hesch J. (1997). Evaluation and treatment of the most common pattern of sacroiliac joint dysfunction. In: Movement, Stability & Low Back Pain: The Essential Role of the Pelvis. Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R, eds. London, United Kingdom: Churchill Livingstone, 535-552.
Hesch J, Aisenbrey J, Guarino J. (June 25, 1990). The Pitfalls Associated With Traditional Evaluation of Sacroiliac Dysfunction and Their Proposed Solution. Presented at Annual Conference of the American Physical Therapy Association, Anaheim, Ca.
Huijbregts P. (May/June 2004). Sacroiliac joint dysfunction: evidence-based diagnosis. Feature Article of the Orthopedic Division Canadian Physical Therapy Association,
18-44.
Huijbregts P. (2008). Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther., 16(3):153–154.
Janiak DD. (2001). Review of sacral somatic dysfunction. AAO, 18-23.
Jordan Theodore R. (2006). Conceptual and treatment models in osteopathy II. Sacroiliac mechanics revisited. AAOJ, 11-17.
Levangie PK, Norkin CC. (2005). The hip complex. In: Joint Structure & Function: A
Comprehensive Analysis. Philadelphia, PA:F.A. Davis, 368-372.
Neumann D. (2002). Axial skeleton: osteology and arthrology. In: Kinesiology of the
Musculoskeletal System. St Louis, MO. Mosby Inc., 303-305.
Sakamoto N, Yamashita T, Takebayashi T, et al. (2001). An Electrophysiologic Study of Mechanoreceptors in the Sacroiliac Joint and Adjacent Tissues. Spine, 26(20):68-71.
Sturesson B, Selvik G, Uden A. (1989). Movements of the sacroiliac joints: a roentgen
stereophotogrammetric analysis. Spine, 14:162-165.
Sturesson B, Uden A, Vleeming A. (2000). A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine, 1;25(3):364-8.
Tullberg T, Blomberg S, Branth B, et al. (1998). Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine, 15;23(10):1124-8; Discussion 1129.Wyke B.D. (1972). Articular neurology: a review. Physiother.,
58:94.
Walker JM. (1992). The SacroiliacJoint: A Critical Review. Phys Ther., 72(12):913.
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