Why your SI joint is not the problem...

Ahhhhh the sacroiliac joint. The “SI joint” for short.

It is the connecting joint between the sacrum and the pelvic crests (i.e. hip bones), and is the subject of much scrutiny in the orthopedic community these days.

I’ve heard it all. Patients have been told their SI joint is stuck, or unstable, or just dysfunctional, resulting in pain or some type of hindered function.

Let’s rip the band-aid off early: no, your SI joint is not the source of your pain, nor can it really be dysfunctional.

Now, let me clarify this statement, because I can already feel the arrows being drawn now.

Notice I didn’t say it is NEVER a source of pain, because it can be, but probably not in the way you are thinking.

This is also a great time to throw out a disclaimer: this is simply a growing point of view that I’m seeing in the research, it is not meant to diagnose you individually or undermine a diagnosis you might already have.

Can you experience pain in your SI joint? Yes, absolutely.

Is the SI joint going to be the direct cause of pain (in a normal situation)? No, most of the time not.

Now, like I said, it would be inaccurate to say that the SI joint is never the source of pain. There are conditions in which the SI joint is the major culprit, however, these are quite specific circumstances.

However, for the general population experiencing spinal and/or pelvic pain, a diagnosis of SI joint dysfunction and falling back on the SI joint as a cause of the pain is increasingly becoming an unpopular decision in the research.

SIJ Pain vs. SIJ Dysfunction

Like I said, you can have SI joint pain, but not really dysfunction. Therefore, we have to understand the terminology.

The idea of SI joint pain is easy: you have pain in the SI joint. (rocket science, I know)

This can be as a result of quite honestly any condition in the lumbar spine. Conditions of the lumbar spine love to refer pain to the SI joint.

The idea of SI joint dysfunction is a little more complicated.

Diagnoses of dysfunction claim that the joint itself somehow has an inappropriate course as it moves through its degrees of movement (whether too much or too little movement), or there is an inability of the musculature around the joint to control it during movement of the trunk and legs.

Though they are not the same definitionally, dysfunction can cause pain. However, pain doesn’t always mean there is a dysfunction.

Keep this in mind: FOR A JOINT TO BE DYSFUNCTIONAL, IT HAS TO BE ABLE TO MOVE.

We will come back to this later.

The research 30+ years ago seemed absolutely convinced the SI joint needed to be considered in all cases of idiopathic low back pain.

Idiopathic = of an unknown origin.

However, over the last couple of years, more high quality research has been published that tells us this idea might not stand up well for too much longer.

WHEN IS THE SI JOINT TRULY BE THE CULPRIT

1. Pregnancy.

The SI joint is heavily supported by ligamentous structures in the pelvis.

However, when pregnant, the female body will release a hormone called relaxin. This hormone is used for the purpose of allowing the pelvis to expand and widen to prepare for delivery.

When this hormone is released, the ligamentous structure supporting the SI joint is compromised due to laxity.

This can sometimes result in pain coming from the joint area, as well as feelings of the musculature working harder than normal, causing soreness.

2. Significant pelvic trauma.

Any time there is significant pelvic trauma, especially with a force on the tailbone or a translational force on the tailbone, there can be rupture of the ligamentous structure holding the SI joint together.

In this case, there would be significant instability, as well as dysfunction.

These are both highly specific conditions in which the SI joint is indicated as a reason for pain or dysfunction.

However, in any other case, the SI joint is much (and I mean MUCH) less important to be concerned about.

2 KEY REASONS WHY SI JOINT DYSFUNCTION IS NOT THE ANSWER

1. You just can’t measure the movement of the SI joint accurately (1).

I don’t even need to say much on this one, just read the following excerpts from articles below…

Freburger et al. – “Measurements of SIJ alignment were unreliable. Therapists should consider procedures other than those that assess SIJ alignment when evaluating the SIJ” (2).

O’haire et al. – “The poor reliability of clinical tests involving palpation may be partially explained by error in landmark location” (3).

Vincent-Smith et al. – “These results suggest that the reliability of the standing flexion test as an indicator of SIJ dysfunction still remains questionable” (4).

Robinson et al. – “…for the palpation test, reliability was poor” (5).

Meijne et al. – the Gillet test (testing symmetry and asymmetry of the SI joint), “as performed in this study, does not appear to be reliable” (6).

I don’t think I need to continue for you to get the point that palpation and examination of the SI joint is quite terribly inaccurate and not at all reliable.

2. There isn’t a lot of available movement in the first place.

As a result of a handful of articles that I read, it is evident that there is extremely minute degrees of movement of the SI joint (7, 8, 9).

You will find that most experts claim there is roughly an average of 3-4 degrees of movement within any given plane, and with any given movement.

Additionally, this reference standard wasn’t assessed by hand. They had to use CT scans just to confirm this amount of motion.

News flash…most therapists and chiropractors don’t have easy access to a CT scans in clinic.

Now if you aren’t great with spatial awareness and are having a tough time visualizing 4 degrees, let me just tell you, it's not a lot of movement at all.

You will hear many professionals claim that there is palpable movement of the SI joint during certain activities, however, as we have already seen, palpation is terrible and movement is sparse.

Sturesson et al. stated that though “a reciprocal movement could be demonstrated in the sacroiliac joints...the movements were 10 times smaller than reported in earlier studies” (10).

Remember what I said above: FOR A JOINT TO BE DYSFUNCTIONAL, IT HAS TO BE ABLE TO MOVE.

As we can see, this joint more so “wiggles” than it does truly move. This poses a huge threat to the concept of it being dysfunctional.

TAKE HOME MESSAGE

Remember, you can have pain in the SI joint.

I am not disputing that.

What I am disputing is the fact that the SI joint can be dysfunctional or be the cause of pain up into your lower back or down your legs.

With that being said, let me end with this food for thought, coming from an article written by Tong et al in 2006…

“Sacroiliac joint dysfunction is diagnosed based on the combined results of several palpatory examinations” (11).

Yeah, so I have two questions here.

For one, if the diagnosis of SI joint dysfunction is based solely on palpatory testing, yet we know that palpation here is completely unreliable, then how can we actually conclude that someone’s SI joint is dysfunctional? (the answer is: we can’t)

Secondly, if we can’t conclude that it is dysfunctional, then how can it be the source of pain? (the answer is: it can’t)

Hmmmmm, quite suspect if you ask me.

Expect this to continue to a be a major point of discussion over the next few years.

I hope you enjoyed this.

As always, thanks for reading!