SI joint patient (Full Version)

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Keith06 -> SI joint patient (November 9, 2006 5:27:00 PM)

26 year old female who presents with pain over the left SI joint > right SI joint. Pain that goes down the left posterior thigh. Left hamstrings very tight when compared to the right.
R Iliac crest slightly higher, R PSIS slightly lower. Iliac crest height and PSIS position can vary from session to session. Supine leg length with left leg longer by 1/2 inch. The left leg lengthens by 2-3 inches with long sitting. In prone position R buttocks is obviously higher than the left. The patient has very limited lumber flexion but full motion in all other lumber motions. Pain is worse with sleeping and upon waking. Activity seems to help decrease her symptoms vs. static positions. I know most of the SI tests are not accurate, so exactly what kind of dysfunction does this look like. Treatment approach?



FLAOrthoPT -> Re: SI joint patient (November 10, 2006 2:11:00 AM)

can you also check the ASLR test for me and then I'll give you an answer. Have her supine, have her do an active straight leg raise. Painful or tough? Then apply pressure at both of her ASIS in a lateral and slightly posterior direction with your palms (your arms crossed). have her try again. any difference? Then try to approximate the ASIS/Illia and repeat the test. Tell me how all of them compare. L ASLR, R ASLR, Left with lateral pressure, R with lateral pressure, L with approximation, R with approximation. How is the pain in unloading, longitudinal leg distraction? Any obvious scoliosis? Any pain in lumbar spine? What about sitting lumbar AROM. Check her flexion and extension weightbearing but not with the stress of standing. Seated flexion and extension of the lumbar spine tells you a bit more than standing flexion extension. What are her crest heights like in sitting. What about sulcus testing of the Sacrum? seated, seated flesion, stork, prone vs prone on elbows? And last, pure PA pressure over the SI joint, spring it, which side is more guarded/painful? 9/10 times the painful side is the dysfunctional side.

Also, a bit more history, when did this start, anything precipitate it? accident, fall off a ladder, jumping off a ski lift, gave birth, pregnant, carries a kid, seated for a commute a lot, seated at work a lot, any sports, golf, soccer, sorry for all the questions, just need a bit more to steer you in the right direction.

Ben Galin, PT, DPT, OCS



ptim -> Re: SI joint patient (November 10, 2006 3:24:00 AM)

You need to look much closer at the lumbar spine, check repeated movements.

If movement of the L Spine has no effect on the presentation, which would suprise me. Perform the SIJ pain provocation tests as described by Cyriax/Laslett as all the other tests describes have been repeated shown to have little or no value



FLAOrthoPT -> Re: SI joint patient (November 10, 2006 11:45:00 AM)

if you ssupect instability and perform a maneuver that increases stability a la external force manual or belt and the symptoms decrease or the pain decreases, how is that not enough evidence for you? Just because the actual SIJ is very hard to study both via imaging studies and reliability of palpation does not mean that everything is lumbar spine. I have treated a many hypo or hyper SI joints with great relief and succes without touching the L spine (if the L spine needs no touching). You cannot be one of those guys who ingore the SIJ just because there isn't as much literature? Any joint that is not surgical options doesn't get as much literature, but it doesn't mean it cannot be a source of dysfunction. I am not saying static or dynamic palpation tells you anything, but when you throw a whole battery of tests for neurodynamics and control and ligamentous stability and you get cross confirming diagnoses and treatment targeted that works, that IS evidence based.

Ben



Keith06 -> Re: SI joint patient (November 11, 2006 5:13:00 PM)

Thanks for the responses so far. The patient started having lower back pain about 10 months ago after working out (heavy leg press). Oringally diagnosed with lumbar disc bulge. She is a very active female who continues to participate in jumping sports (basketball, volleyball.) Feels o.k. during these activities but describes soreness in the left SI joint afterwards. Fabers, ASIS compression, ASIS gapping doesn't bother her. Her SLR test on the left is painful and limited to 30 degrees. With stretching we can get the hamstrings to 80 degrees in supine. It seems once you fight through this barrior the motion improves. Could the hamstrings on the left be overactive vs. just tightness to help stabilize the SI joint.
No scoliosis noted, no pain with leg distraction, occasional pain over the L5/S1. P/A's to sacrum are not painful but are to the left SI joint. Prone on elbows and Hands doesn't cause any problems and lumber extension is full. The patient does sit a lot. Subjectively reports that most of her pain feels like it is over the sacrum/left SI. Repeated lumbar movements don't change any symptoms. I will work on answering some of your other questions during the next visit. Thanks for your time.



MikeBptatc -> Re: SI joint patient (November 12, 2006 3:25:00 PM)

Check out: Manual Therapy Volume 10, Issue 3 , August 2005, Pages 207-218
This article is very interesting regarding how to rule in/out the sij with significant confidence. The lead author is Laslett as referenced by ptim.

Ptim, do I detect an Aussie base to your manual education?



Shill -> Re: SI joint patient (November 13, 2006 5:07:00 AM)

Keith.
You seem to have more to go on that directs one away from the SI joint than toward it. Given that, I would follow ptims advice. Sometimes it takes up to 3-5 sets of 10 repeated, unloaded, (supine flex or prone extension) movements to start to see a difference. Dont toss it out as a viable approach just yet. She doesnt need to move through full range either, if half range reduces or centralizes pain. It is my experience that most pain of this sort can be successully treated with repeated movements through some range, or all range, with or without a shift, with or without stabilization of the pelvis, with or without segmental mobilization as well.
Overactive hamstrings is a tough and perhaps unnecessary thing to quantify and it might be a stretch to suspect as a cause in this (or most) case(s).



ptim -> Re: SI joint patient (November 13, 2006 12:08:00 PM)

Ben
I was just suggesting that you thoroughly explore the L Spine before investigating the SIJ.
The testing as described by Laslett are the only tests that have shown any reliability, and Laslett said the L Spine has to be ruled out first.
Though the tests are described as provocative tests, a test that reduces or abolishes the symptoms, may also be described as positive, and will also give mechanical determined directional preference
How do you determine hypo or hyper?
There's not much literature on the SIJ??? Your looking in the wrong places!!
There's plenty of evidence to refute your battery of tests.
Try flexion in sitting for 24hrs.
Mike, otherside, UK



FLAOrthoPT -> Re: SI joint patient (November 14, 2006 2:01:00 PM)

That is like saying everyone who sits with poor posture will have back pain, and everyone who does not will not. We all know that without anatomical predisposition physiological findings are rare. If I have no significant injury to my annulus or longitudinal ligamentous stability, chances are I can avoid a herniation from sitting. Mechanically with creep it may eventually get to a point that these above pre-conditions may occur, but you cannot say a = b so b = c. Just because someone has not written a book, though richard jackson, diane lee, dontigny, and others would beg to differ, does not mean that something like an SI is not responsible for pain. Work near a pain mgmt group, have them selectively inject a SIJ you think is a source of pain, if the pain goes away, then now what, coincidence they were sitting doing mckenzie exercises prior to the injection? I think the orthopedic world is unfortunately driven by research based on needs and wants of orthopedic surgeons and therefore L-spines are studied long and hard and htought to be the source of all lower quadrant pain. You cannot ignore the SIJ, let me gues syou think since the ribs are never studied and not prolific in publications, that they too can never be the source of pain or dysfunction. so everyone walking around with pain between their iliac crest and gluteal fold must have lumbar issues? I hope you aren't anywhere where you can spread your lack of foresight and ability to accept what is in front of you, just because the wheel hasn't been invented doesn't mean people weren't looking to discover it. Just because the SIJ is not prolific in literature does not mean that there is not a lot to lear about it. Take a patient with suspected SI hypermobility with laxity biasing their anterior fibers, approximate their ASIS in weightbearing,a nd have them reproduce a functional activity that was painful such as a single leg squat. So when pain is gone, does that mean I have changed their lumbar mechanics? What about the person who cannot forward flex or is forward flexed in standing, but when you sit you can bring them through weighted but non-standing lumbar AROM in a much greater range, how do you ignore the pelvis? I wish you an awakening one day, until then happy tunnel vision-
ben galin, pt, dpt, ocs



ptim -> Re: SI joint patient (November 15, 2006 2:43:00 AM)

Ben
Do you actually read what is posted, or just log on and start ranting on about what ever comes into your head?
I don't recall mentioning anything about a disc! I did say before investigating the SIJ you have to thoroughly investigate the L Spine.
I see and treat SIJ all the time, but I use a system to get to this conclusion. I've seen numerous patients with lumbar pathology that have false positive SIJ tests and the palpation/symetry tests just have no proven value, its not that they haven't been investigated, they have and they are not valid.
I think if anyone has tunnel vision, that would be you.
Oh and before you reply, please read what is written and think before you write!



FLAOrthoPT -> Re: SI joint patient (November 15, 2006 4:12:00 PM)

I cannot believe people think the red sox are spending too much money on this guy. Do they not see that the money generated worl wide on merchandise and tv contracts alone owuld pay his salary, and if he is even just good, he will compliment an already awesome lineup. Just need some help in the bull pen! I think if the yanks did it no one would care, but now that the red sox want to be contenders everyone thinks they are crazy!!

What was it you were saying about even reading? what were we talking about?



FLAOrthoPT -> Re: SI joint patient (November 15, 2006 4:16:00 PM)

seriously though, my guess is you are an unfortunate byproduct of either a mentor, co worker or school such as USA that is so afraid of treating things that are not in JOSPT that they refuse to admit that they can be sources of pain or dysfunction. If you look at how a dome or arch is structured and imagine putting a seem in it, can;t you see mechanically how this would be a point of mechanical stress and failure? But really now, those sox are just smart, theo epstein for president.

But really now, aren't boards like this for people who rant time to time? If it wasn't for fierce conversations we'd still be putting all LB patients on bed rest. Read the posts on fierce conversation, I think you just need to get over your ego and realize this board is full of fierce conversation with no ill intent other than to challenge your beliefs, but to say "i think this just because" isn't going to cut it on here.

But really, those sox, bravo.



ptim -> Re: SI joint patient (November 16, 2006 3:17:00 AM)

Please read what was written, then think about what was written, then try and make an intelligent comment!
Why would I investigate the SIJ if I didn't think it was a source of pain or dysfunction?



FLAOrthoPT -> Re: SI joint patient (November 16, 2006 2:05:00 PM)




FLAOrthoPT -> Re: SI joint patient (November 16, 2006 2:08:00 PM)




Keith06 -> Re: SI joint patient (November 16, 2006 4:12:00 PM)

Back to the original patient problem. I tried a lot of you guys suggestions. Based on stork test and standing flexion test the R side is hypomobile. Her pain is mainly along the sacrum, left SI joint, and down the left posterior leg to the knee level. ASLR limited to 40 degrees on the left and 80 degrees in the right. Both cause pain the left posterior buttocks. ASIS compression completely relieved her symptoms. Repeated lumbar movements did not eliminate or significanly increase her pain levels. Iliac crest height was fairly even in standing and sitting. Supine leg length showed a .5 cm longer leg on the left. When moving into long sitting the left leg went to 4-5 cm longer. PA pressure over the SI is not that painful on either side, but the pt. does state it makes the left side feel sore. PA's to L4, L5 are painful also. Tenderness is noted with palpation to the left piriformis and glut maximus. R SI mobs are more hypmobile when compared to the left. R Hip PROM is slightly less than the left side. I am sure there could be more than one issue going on here. Any thoughts on treatment, MET's don't seem to help with evening up the supine to long sitting leg length test or decrease the pain. ASIS compression decreases pain and hamstring stretching helps, but the gains in length of the hamstrings just doesn't last.



MikeBptatc -> Re: SI joint patient (November 17, 2006 7:03:00 AM)

Bottom line, EVALUATE the patient and use the current research. IF there are things in the lumbar spine to treat then treat the patient there. IF you apply the SI tests as applied by Laslett after the lumbar spine has been ruled out and they are positive then treat that. IF this information fails to help the patient then use your clinical skills to further evaluate the patient, get help from a colleague or get smarter somehow. The best evidence should always be used. It is when that fails that we need to use our clinical skils to the fullest so that we are not stumped by those who meet certin criteria set forth by research without a favorable outcome after treatment.
FLAOrthoPT - the rant was funny, I'm sure had meaning at some level and to someone, but was a bit overboard. Yes or no, have you read the Laslett article. If not, you in fact may be the victim of "an unfortunate byproduct of either a mentor, co worker or..."
GO SOX!!!!!!!!!!!!!!!!!!!



ptim -> Re: SI joint patient (November 17, 2006 9:53:00 AM)

Go Mike!!!!



Randy Dixon -> Re: SI joint patient (November 17, 2006 7:16:00 PM)

Use an SI belt on her. Since you have relief with compression there is a good chance this would help. If it does then hip instability seems pretty likely.

The difference between left and right is more important probably than the absolute numbers of either side. SIJ pain is correllated with muscular inhibition similar to the way CLB pain is. The tight hamstrings suggest this is an issue.



FLAOrthoPT -> Re: SI joint patient (November 17, 2006 8:13:00 PM)

this person has signs of lig laxity of her SI. Would do well with core stab, rhytmic stab of muscles around sacrum, all things on medium wieght, closed chain if possible no single leg stance, small amplitude movements. Supine with blood pressure cuff good place to start. Get them in an SI belt, work from there to stabilize muscularly. PS I stopped reading and learning after I graduated.



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