In our Boulder County physical therapy practice, we are observing a resurgence of the use of clinical tests by some area providers to determine mobility and position of the sacroiliac joint (SIJ) not only to explain posterior pelvic girdle pain, but also lower back, hip issues and beyond. Approximately 20 years ago, the tides began to change in manual therapy, moving away from these constructs based on best-available evidence. Here we review some key points about the SIJ. 

1. The SIJ does not change position with manipulation. 

A seminal study published by Tullberg et al in 1998 utilized Roentgen stereophotogrammetry (a high precision measurement of 3D motion in skeletal joints) before and after SIJ manipulation and found no significant change in position of the SIJ despite change in positional tests commonly used by clinicians. A more recent study (D.F.A de Toledo et al, 2020) assessed the mobility of the SIJ before and after manipulation utilizing 3-dimensional motion capture and came to the same conclusion – high velocity, low amplitude (HVLA) manipulation of the SIJ does not change mobility or position. 

2. The clinical tests commonly used to assess the position of the SIJ are unreliable 

This is for a number of reasons including: available movement at the SIJ is exceedingly small and unable to be detected by palpation, wide variability in bony landmarks and lack of validity of clinical tests to detect movement. Numerous studies report the reliability and validity of positional tests to be worse than a coin flip rendering them useless to aid in clinical decision making. 

3. Manual therapy (hands-on treatment) is effective at reducing pain but the reasons why are evolving with emerging research.

We now know that the effects of manual therapy are widespread and have more to do with neurophysiological effects (changes in our nervous and endocrine systems and muscle responses) than structural change. Furthermore, we know that the context under which manual therapy is applied matters. For example – being told that your SIJ is “out of alignment” or “unstable” can promote negative beliefs or behaviors such as fragility or activity avoidance, which negatively impact prognosis (known and nocebo effects). Conversely, positive therapeutic context developed by collaborative decision making, reassurance that there is no permanent or harmful pathology present and an approach that involves movement and exercise in addition to manual therapy dramatically improves prognosis. 

So what does this mean for treating my SIJ or other painful areas where I think my SIJ might be an issue? A high quality, evidence-based orthopedic examination should include thorough questioning of your pain and history, and a physical examination that uses effective and informed techniques. At Mend your physical therapist will work with you to identify the source of your pain as well as contributing impairments. An effective treatment will likely include a combination of manual therapy, exercises and education that are directed by our current best understanding of the mechanisms of SIJ and musculoskeletal pain.”

To learn more about our evidence-based approach to managing SIJ, hip, pelvic and lower back pain, please contact the experts at Mend.