Email: SIJ Dialogue
This is an email correspondence I recieved, and my reply which follows.
----- Original Message -----
Sent: Monday, August 03, 2009 3:45 AM
Subject: About your writings of SIJD in PTJ
About your writings of SIJD in PTJ
You don't seem to understand that SIJD is not pain in SIJ. Pain is just one
symptom of the dysfunction. If you use provocation tests you find only those
SIJD cases with pain in SIJ area (and that may give a false diagnose and you
may start manipulating the healthy side of the pelvis!!)
Then you tell using palpation gives false results? With palpation you don't
look for pain but the dysfunction (asymmetry). That's why it gives different
results: It finds also the patients who have SIJD but not yet SIJ pain or
restriction. Why it is a false result???
SIJD is quite common with children too, but the symptoms appear usually
I had left ilium upslip and pain was on right side (and a lot other symptoms
too). It took a while to find an expert who didn't confuse pain and
dysfunction, because pain is usually on the other side than the dysfunction
as only some experts seem to know (One is Darren Higgins, teaching
manipulative methods to physical therapists, Manual Therapy Seminars of UK).
Pain can be in neck or upper back, and the reason still is SIJD without any
pain in low back or SIJ area.
Tullbergs study tells manipulation doesn't alter the SIJs, even the study
was only with 10 patients.
99% of the "experts" don't know how to correct SIJD. It is hard to find one.
I wonder who did the manipulation on that study?
It's like if 10 people try to ride with unicycle. No one succees and they
response that it not possible to do.
My Reply August 3, 2009
We have much in agreement.
I only mobilize joints that are stuck, this is a movement model.
I specifically do not trust pain provocation tests for this region, so we
are in agreement. This for a variety of reasons, though I will not expound
here. However, I do respect pain, and in addition to having functional
goals, do have pain relief as a goal of care. Many so-called pain
provocation tests cannot help but stress other proximal, structures.
Injection ion the joint is also problematic, because the joint is innervated
by L1, L2, L3, L4, L5, S1, S2 +/- a segment. The injection can reduce the
threshold of referred pain, so it does not always validate that the source
of pain is in fact the SIJ.
I always evaluate and treat both sides when appropriate.
The letter to editor does not encompass the length and breadth of my body of
work, it is extensive.
Palpation alone can give false positives. Palpation along with general
mobility tests such as the standing flexion, sitting flexion, long sit, etc,
are not a good combination. To interpret these and say that a pelvic
landmark does not move symmetrically with the opposite side implies
dysfunction within the SIJ, is a bizarre belief system that has existed for
too long. I published and presented on this in 1990, 1992.
I actually agree with you that SIJD is rarely pain within the SIJ itself,
and there are many more who present with apparent SIJD who may even be
asymptomatic-again we are in agreement.
In the presence of a biomechanical dysfunction of the SIJ, the pelvis, the
SIJD, etc, the body always compensates, so a secondary dysfunction can
manifest in the upper body as you state. This is why I evaluate the pelvis
in every single person I treat. The occulo-pelvic reflex is one of the
strongest in the body. In fact, I evaluate from head to toe, in a variety of
contexts. It is not unusual to encounter a primary or secondary dysfunction
on the foot and ankle, which is amenable to mobilization, and exercise.
I would submit that most people with SIJD have bilateral dysfunction,
regardless of side of pain. Resolving pain does not mean that the problem
has been optimally resolved. One must be very thorough and evaluate mobility
in a variety of contexts, not just standing, sitting, prone an supine, but
also end-range extension and the position that most clinicians do not test:
full flexion AKA Muslim Prayer Position or in Yoga; Child's Pose. I would
sincerely be surprised if spring tests were performed on you in Muslim's
Prayer position, but if wrong I will humbly proclaim that I am wrong. I
usually learn something when I am wrong. Wisdom comes from experience (and
paying attention, studying). Experiences bring failure (and success). I like
to learn form both, success and failure. no clinician succeeds all the time,
except perhaps in their own mind!
I use many more passive motion tests and the very manner in which I perform
them is more thorough than the traditional manner of performing spring
tests. I therefore refer to mine, at the suggestion of a very bright manual
therapist who studied with me: "Springing With Awareness".
Much of so-called SIJD is actually biomechanical dysfunction of the hip,
lumbar spine and the pelvis itself. I happen to have a true SIJD, which I
manage very effectively based on my own discovery of more than a dozen
advanced patterns not described in the literature. You can review several CT
scans and MRI's taken over the course of 15 years and you can see the
significant developmental asymmetry of the joint and of the primary
Yes, number of participants in the study you reference was small, but
please, if a study (that has been replicated, etc) exists with a larger
population, please share. There are many studies that show very small motion
in the SIJ.
I treat SIJD in many populations. It is generally accepted than motion in
the SIJ will oftentimes be increased in the peri-partum and post-partum
population. I sincerely believe it does exist, however, many times it is an
exogenous problem. The analogy of unicycle does not apply here. Nowhere have
I stated that true SIJD does not exist.
I am very confident in my skills in evaluating and treating this unique
region of the body and welcome an opportunity to compare evaluation on real
clients and document in the form of a research project to include video,
presentation and publication.
I would be interested in reading additional writings that you may have.
Please feel free to schedule a phone call if you would like to further
discuss the topic.
Jerry Hesch, BS, MHS, PT
Founder of the Hesch Method