RE: si joint treatment

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RE: si joint treatment - August 22, 2008 9:05:59 AM

PTupdate.com

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From: Pittsburgh, PA USA
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Steve.....can't bet on the Pirates...they suck. I guess I could be they will lose.....

As far as your patient scenario. Either femoral nerve, as noted by Kongen, OR mechanical pull of the rectus femoris on the ASIS, relieved as you apply pressure the other way. I have seen this with many mechanical back pain patients....once the nerve is cleared, the quad/rectus stretch causes an anterior pelvic movement, and thus spinal extension, and can exacerbate pain. Quad stretches...both for the muscular component, and also due to the neural component, have been part of my low back program for YEARS. Barrett Dorko and I talked about this a few years back, once I realized that not all the gains seen were truly musculoskeletal, but neural as well.

_____________________________

John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com

(in reply to Kongen)

Post #: 21

RE: si joint treatment - August 22, 2008 9:23:51 AM

proud

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Kongen,

Could be. Would have to differentiate between femoral nerve and jointy stuff through. As Duffy stated, spinal extension occurs with the knee flexion and is decreased by the the pulling up on the ASIS.

You can differentiate the two by testing the femoral nerve is sidelying using head flexion /extension as your differentiating movement.....

(in reply to PTupdate.com)

Post #: 22

RE: si joint treatment - August 22, 2008 10:04:46 AM

bobmfrptx

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Joined: December 12, 2006
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I used to analyze, test and figure what was what in regards to the SIJ. Upslip, torsion, nutation...shove here, tighten there yank and crank. even bought a book Osteopathic Lesions of The Sacrum by Raymond Richard. Very confusing when trying to look at the 64 different variations of movemnet allowed by the 6 axes described in the text. Used reverese Erhard manips as well as Rocabado's, (very similiar) Confusing in application and not necessary in my opinion. (lumbar manip for SI complaint...well you do push on the ASIS ???)
Now I do a lumbo-sacral decompression which is essentially a technique to "balance the sacrum and lumbar spine" . It works in all cases and is described here. http://physicaltherapy.rehabedge.com/m_55867/mpage_1/key_/tm.htm#56104

I then follow with isometric adductor squeezes using a basketball between the knees in hooklying...usually the patient gets an audible click and feels discomfort at the pubic symphysis with the first contraction. the next 8 to 10 usually result in no click and the feeling of increased strength subsequent to a more "alligned" axis of rotation for the innominate bones.
Isometrics are prescribed 3 times daily but more if you desire....A.M. prior to arising from bed....before sitting down for supper....and in bed before going to sleep. Directional movements follow on the second visit as long as symptoms continue to be minimal and on the third visit MET. (isometrics to me) are prescribed for stabilization of the larger muscles i.e hamstrings, quads, rectus abdominus, which act upon the innominate bones. Elongation 3 dimensional stretches,which I have devised, are given as well . ( most today would call these neural gliding techniques, but I just use elongation since it is impossible to separate nerve from fascia from myofascia from etc etc etc) 4 to 5 visits seem to be enough for the mild to moderate cases...8 to 10 for the more complex.

< Message edited by bobmfrptx -- August 22, 2008 11:36:49 AM >

(in reply to proud)

Post #: 23

RE: si joint treatment - August 22, 2008 11:17:54 AM

PTupdate.com

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Bob notes the MET of the pubic symphysis.....that "Shotgun" technique is so very important, and it seems when audible/palpable cavitation does not occur, or you can feel the subconscious apprehension during the adductor squeeze, that the outcomes are not as immediate. It seems like that technique "finishes the job". It was once explained to me that there are 3 links in that pelvic chain....the 2 SI joints and the pubic symphysis. Dysfunction at one may cause pain....at 2 causes much more severe pain.

Just a few months ago, my secretary had what appeared to be a significant rotation. We took radiographs before and after the MET to see if anything changed, using the lines drawn on landmarks as noted in the Autotraction Text....I still have to sit with the spine surgeon and see if we caused any visible change on radiographs. I thought that might be a nice first step in publishing something on this topic.....visible evidence of a malposition, corrected with a therapeutic technique.

Thoughts on this?

_____________________________

John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com

(in reply to bobmfrptx)

Post #: 24

RE: si joint treatment - August 22, 2008 12:56:49 PM

Shill

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From: Madison WI USA
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John,
I'd like to see if you get results of an identifiable positional change. All I have seen are drawings of a malpositioning possibility, without radiographic evidence.

In regards to my prone knee flexion thingy. This can often occur in the absence of any true resistance or end feel. Im not sure that the anterior to posterior gliding that I produce would actually shorten the femoral nerve an appreciable amount, as the observed changes in the pelvis are quite small, but I have entertained this structure as the reason for the change. However, it often allows the knee flexion motion to go from just over 90-100 degrees, to nearly full heel to buttock, which I would imagine would pull even more on the femoral nerve.

Proud - I dont think I have ever re-checked femoral nerve test in sidelying with the same anterior to posterior force on the ASIS. Good idea.

(in reply to PTupdate.com)

Post #: 25

RE: si joint treatment - August 22, 2008 1:28:54 PM

Kongen

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Proud, Shill,

If fixation of the pelvis (reducing the stress on the "jointy stuff") during prone knee bend increases lumbar pain or the resistance to knee bending, my thoughts go to the femoral nerve.. sometimes the pain increases considerably, sometimes it decreases... One can also use side lying as well as mentioned by Proud. If one lifts the ASIS, one will alter the mechanical interface of the femoral nerve.. I've seen a severly painful and restricted prone knee bend (20 degrees of the table!!) disappear after lumbosacral manipulation.

(in reply to Shill)

Post #: 26

RE: si joint treatment - August 22, 2008 2:31:31 PM

Tom Reeves DPT ATC

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John,
I really think that it might not show what a spine surgeon or radiologist would consider a significant positional change. BUT I think that very small movements or lack of movements are pain generators.

I once had a patient who had 15 years of SI pain that was very debilitating to her. She was unable to work as an activities coordinator at a nursing home because of it. I would routinely find pelvic assymetries and would easily correct them with MET. She would immediately feel better but they would come back. I had every confidence that she was compliant with directional isometrics at home to maintain the position but it kept coming back.

I asked her PCP to do unilaterally loaded AP pelvis films to look for potential Pubic symphysis instability. Lo and behold, when she stood on her L her L pube moved up 3-4 mm and when on the R the R pube didn't move. naturally, the radiologist said that it was a normal variant associated with childbirth. I still tried to find an orthopod or physiatrist that would inject her pubic symphysis to sclerose it down and was unable to find one. (I suggested it in the note I ultimately sent with her when she went to a spine surgeon.) She ended up getting her SI JOINTS FUSED!!!!! AAAAAAARRRRRGGGGGHHHHHH!!!!!!!

Of course that didn't work so they then implanted a TENS unit and now she is like Cliff Claven when he went through behavioral shock therapy. ("Dance mailman")

Please let us know once you have looked at the films.

< Message edited by Tom Reeves DPT ATC -- August 22, 2008 2:48:22 PM >

(in reply to PTupdate.com)

Post #: 27

RE: si joint treatment - August 22, 2008 2:51:21 PM

grifffdog

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Prone knee flexion and/or hip extension can reproduce femoral pain with a disc problem at the higher levels in the L spine, a fact I learned the hard way. As the femoral nerve is not stressed by a SLR or slump test, it is an atypical pain pattern from the L-5 or S-1 nerve root pain pattern. L 2,3,4 discs are relatively uncommon and may escape notice. One may think MM tightness or neural tension when assessing "SIJ" pain prone, when in fact one is doing the SLR for the femoral nerve.
Phil Greenman has his "dirty half dozen" listed in his text. Though lacking research support, I find it helpful to check these problems with patients who don't respond as I expect to treatment of SIJ or L spine problems. The list has been of great utility to me,despite the acknowledged lack of research support.

(in reply to rwillcott)

Post #: 28

RE: si joint treatment - August 25, 2008 5:29:12 AM

Kongen

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Another thing about the SI-joints and their supposed "dysfuntion" is ofcourse which side is dysfunctional? The symptomatic / painful side or the other one? :) Lot's of anectdotal evidence and other biomechanical rationale is circulating .. What is your experience?

(in reply to grifffdog)

Post #: 29

RE: si joint treatment - August 25, 2008 9:39:59 PM

bonez

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For once I agree with proud. I will add that I sometimes have a concern for flare of the pelvis as well. I see a lot of the didn't fix elsewre problems and pelvic flare usually seems to be present on these cases too.

(in reply to proud)

Post #: 30

RE: si joint treatment - August 26, 2008 11:59:04 AM

grifffdog

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Phil also said "don't chase pain, pain is a liar". I have seen folks with pain on one side, restriction on the other, one sided pain, two sided restriction, bilat pain and restriction, etc. Treating what are the significant problems and letting the pain take care of itself for the first treatment or two seems to work pretty well when I get the patient on board with a musculoskeletal/biomechanical approach as opposed to the "disease model" of their problem. Of course, all the usual caveats apply: no missed pathology, etc, etc.

(in reply to Kongen)

Post #: 31