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Episode 67: Popular Explanations for SI Joint Pain are Wrong, Says Science
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Welcome to Episode 67 of the Movement Logic podcast! In this episode, Laurel and Sarah discuss what current science, versus outdated advice and conventional wisdom, have to say about the causes and solutions for sacroiliac joint (SIJ) pain. Learn what research says about whether or not the SIJ is an inherently robust or fragile structure, whether things like lots of stretching in yoga or joint laxity during pregnancy contribute to its instability, and what therapists can and cannot reliably know about the causes of SIJ pain.
You will learn:
- The anatomy and biomechanics of the SIJ.
- How Sarah differentiates between low back pain and SIJ pain with her patients.
- What joint incongruency is and what therapists can and cannot know about joints through palpation.
- What amount of force is required to dislocate the SIJ.
- What SIJ form and force closure are, and how they are used to explain SIJ pain.
- Some common explanations, assessments, and treatments for SIJ pain that lack evidence.
- Why muscle testing is an unreliable way to assess muscle strength or weakness.
- The problem with muscle imbalance theories.
- How upper and lower cross syndrome theories —the idea that muscles can be “locked short” and “locked long”— has since been replaced by more contemporary research.
- What evidence-based tools we have to address SIJ pain.
And more!
Sign up here to get on the Wait List for our next Bone Density Course in October 2024! It’s the only place you’ll get a discount on the course.
Episode 21: Is the SI Joint Painful Due to Instability?
Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint
The sacroiliac joint – Victim or culprit
A radiostereometric analysis of movements of the sacroiliac joints during the standing
Clinical tests of the sacroiliac joint.
Effects of mobilization treatment on sacroiliac joint dysfunction
Association between the serum levels of relaxin and responses to the active straight leg raise
Effects of mobilization treatment on sacroiliac joint dysfunction syndrome
Recommended
Transcript
Introduction to Movement Logic Podcast
00:00:02
Speaker
Welcome to the Movement Logic podcast with yoga teacher and strength coach Laurel Beaversdorf and physical therapist, Dr. Sarah Court. With over 30 years combined experience in the yoga, movement, and physical therapy worlds, we believe in strong opinions loosely held, which means we're not hyping outdated movement concepts. Instead, we're here with up to date and cutting edge tools, evidence, and ideas to help you as a mover and a teacher.
Sarah's Fitness Journey and Equipment Choices
00:00:39
Speaker
Hey everybody, welcome to season four of the Movement Logic podcast. I'm Laurel Beiberstorff and I'm here with my co-host, Dr. Sarah Court, DPT. Hello. That's me. Sarah, what's happening? What's going on? I mean, she says with a deep sigh. I mean, honestly, the biggest thing going on in my personal life right now is I am debating
00:01:07
Speaker
getting a rowing machine. Oh, nice. Yeah. What is this? Like, I want to get a rowing machine. Well, so as some of you may know, I've been working on getting more sort of cardiovascular exercise and really that sort of moderate to vigorous intensity. I've been a hiker as long as I've lived in LA, but it's not, it doesn't really get your heart rate up. And so I started doing some jogging, which has been going fine. But I also have sort of like, you know,
00:01:40
Speaker
It's good to have options. It is good to have options. And I'm thinking about things like, you know, I have joints that have proven themselves to be, let's say, not the strongest. And also, I'm kind of hypermobile. And so cardio exercise where it's actually kind of closed chain, I think, in some ways might be good
Rowing vs. Other Cardiovascular Workouts
00:02:00
Speaker
on my body. And also, like you're saying, it's good to have options, good to be able to do different
00:02:04
Speaker
type of exercise. And I kind of got influenced because I didn't take an orange theory class, but I was in an orange theory studio. They do classes where it's like, there's some treadmill and there's some rowing machine and then there's weights. So it's sort of like a very hard looking class actually, in my opinion. But anyway, I did, I did an orange theory class once and I actually really liked the treadmill part of it. Yeah. And that's about it. The reasoning they give for using rowing machines as well as treadmill is they, they say,
00:02:31
Speaker
that the rowing machine uses 85% of the muscles on your body. Now I have no idea if that's actually true, which muscles they're using or not using, but I did row crew very, very briefly in college. I got recruited because I was tall. And I was actually decent at it because having a sort of dance background, I understood like the choreography of the shape. But the thing that I wasn't was particularly in shape at all.
00:02:58
Speaker
All of the women who had come to like college rowing from being high school rowers who are kind of badass did not appreciate the fact that I got put in the front of the boat because my form was good because the people in the front of the boat are usually the people who are like, you know, the A plus whatever.
00:03:15
Speaker
But with that said, I enjoy a rowing machine, the manner in which you effort. And to be able to do that kind of consistent efforting, I'm going to be able to get more of my 150 minutes a week in faster with this versus running where I'm really having to build up to it because I'm not a runner. So my longest run so far is a mile and a half. I'm not
00:03:37
Speaker
and I'm stopping to walk in
Indoor Cycling and its Benefits
00:03:38
Speaker
between. So I'm sort of thinking that this might be an alternative, but also a kind of faster way to get, you know, I don't have to warm myself up into... No, it's not, it's no impact, right? Exactly. Yeah. So I actually have a bike that I rode in New York City and it's just been sitting in my garage because I'm actually terrified of riding my bike on the road in Alabama, like terrified. And you would think it'd be the other way around. Why? I'd be like afraid of riding in New York City.
00:04:05
Speaker
The drivers here are not incredibly vigilant. And also, there's not a bike culture here like there is in New York City. Or just pedestrians rule the road in New York City. Cars are second-class citizens. Here in Alabama, there's not a whole lot of bikes on the road. Cars aren't expecting to see them. I would say car culture.
00:04:25
Speaker
Car culture is really strong here. Same in LA. I'm just afraid. Whether or not it's rational, I don't know. Anyway, I also trained for a half marathon and was like, wow, I just did a lot of running and I need to find another way to get my cardio because a variety is the spice of life. Running injuries are an insidious onset type injury where suddenly this or that or the other thing is breaking down because
00:04:54
Speaker
you probably need to be doing more than just running, right? We've heard this before. Anyway, I bought what's called an indoor trainer. It's basically just a stand that you hook the back wheels of your tire into and then they spin on a roller.
00:05:12
Speaker
And you can adjust the resistance level of the roller, but then you can also adjust your gears so that you are working at different resistance levels. And then you fixture your front tire into like a little holder. And I love it. I can like watch Netflix and Ride My Bike. It's like more of a front body dominant exercise, whereas running is much more of a back body.
00:05:33
Speaker
like hamstrings and calves versus quads, right and hip flexors. So I already feel like it's making a very positive difference and just how might like you said how my joints feel. Yeah.
Bone Density Course Impact
00:05:44
Speaker
Cool. Yeah. Cool. Thanks for sharing. I'm gonna read a
00:05:50
Speaker
BDC bone density course testimonial as we've been doing and this one is so amazing. I just love this one so much. So it's from Bridget and she writes in our Facebook group, this was after the last class or slightly before the last class, I can't remember, but it was kind of a farewell type of post to this
00:06:10
Speaker
particular cohort and she writes, thank you everyone. I've learned how to ride the waves and build a solid habit that will lay a foundation for the life I've envisioned for myself but didn't know how to achieve. I feel strong because I am now strong.
00:06:24
Speaker
I am confident because I've learned the skills to manage the fluctuations that will undoubtedly arise knowing that I'll still grow through the challenges and growth isn't linear. I used to count on others to have the strength I'd need, but now I can count on myself for those tasks.
00:06:43
Speaker
It feels fucking fantastic to carry a huge box up the stairs, to move that enormous plant to another floor, to carry those awkward items, and pull myself up and out of a dangerous situation. This course has deepened a feeling of empowerment and trust in myself that is lighting me up. Thank you. Thank you. Thank you. Oh my God. I know. Oh my God. Thank you. Thank you for writing all of that.
00:07:12
Speaker
Thank you for being such a active participant in the live classes, for being so vocal in the Facebook group, for lifting other people up with your leadership. It's been a pleasure and a privilege. I love what she says about managing the fluctuations that will undoubtedly arise.
00:07:32
Speaker
knowing that I'll still grow through the challenges. Can you speak to what you think she's talking about there, Sarah? So for some of the women in the course, as they were progressing through the six months, certain things cropped up that were sort of like rocks in the path. Christmas and New Year's, which we didn't really sort of think about, but for a lot of us, including myself, around the holidays, we tend to either lose steam
00:08:01
Speaker
It's the end of the year. We're tired. We're in this sort of celebratory period, whether it's, you know, whatever holiday Christmas or Hanukkah or Kwanzaa or any of those, right? There's sort of this sense of like, be with family, relax, eat a lot of food, cozy
Forming Long-term Habits and Setback Management
00:08:13
Speaker
sweaters. It's not like, let's PR my deadlift. You know, that's not the vibe, right? So for a lot of people, they got a little bit out of their habit of taking the classes and maybe it took them a couple more weeks than they thought it would to get back on track, but they did.
00:08:31
Speaker
And for other people, like Bridget is one of them, they had some injuries that cropped up, maybe an old injury that suddenly started hurting again, or they did something funky outside of class and now your elbow is feeling strange.
00:08:43
Speaker
some of the women then reached out to you and I for personal guidance on how to get back into the course, which we were able to give them. And some of them just kind of figured it out on their own, which is pretty much what Bridget did. She sort of explained what was going on, but she basically was like, so I'm going to do that instead of this. Is that cool? And then we were like, yeah, go for it. Tell us how it goes. So certainly that resilience around
00:09:07
Speaker
not being thrown off being like, oh, well, this happened. Therefore, I shouldn't be lifting at all. I shouldn't be doing anything. This program wasn't right for me. Just kind of managing it, working with it or around it.
00:09:20
Speaker
and getting back on track. And the way that she understands that progression isn't linear is really fantastic because, and that's something that you and I promoted a lot during the course, right? That it's not a straight line, so you might as well get used to it. Any habit you cultivate over a long period of time will have a non
00:09:40
Speaker
linear progression in terms of your advancement because life happens, right? So if we want to treat strength training like other habits that we have, that we've always had, that we've had an easier time maintaining, like maybe brushing your teeth or eating vegetables or getting enough sleep or going to church or whatever your healthy habits are, right? We have to be willing for there to be obstacles, for conditions to be less than ideal.
00:10:09
Speaker
for there to be periods of time where we do get derailed and then get back to
Sacroiliac Joint Stability: Myth or Reality?
00:10:17
Speaker
it, right? We have to practice getting back on the wagon, right? And so that was like a running theme in the group about falling off the wagon, getting back on the wagon. And honestly, I actually think that that was ultimately what I wanted to teach in this course, right? Which the process of making this a habit
00:10:35
Speaker
for a long term, not just six months, but lifelong habit. We are currently holding open the wait list for the bone density course and we would like to entice you to join the wait list because this course is life changing and we think you should be a part of it.
00:10:53
Speaker
if you want a discount and also if you want to get some really valuable resources that are only going to be made available to the waitlist like for example Sarah shared her how to know when it's safe to exercise when you're in your decision tree as a freebie giveaway like there's going to be other
00:11:12
Speaker
valuable waitlist only tools like that shared as well, and you want the biggest discount available, and the only discount available for the course, you're going to want to get on the waitlist. You can also not get on the waitlist and pay more. That's fine too. The choice is yours. But if you want to get on the waitlist, the link to do that is in the show notes. Yes.
00:11:35
Speaker
All right, today we're delving into common beliefs surrounding the sacroiliac joint and specifically we're doing this to investigate a question. A question of whether or not the sacroiliac joint is inherently robust and stable or easily prone to instability
00:11:53
Speaker
or slipping, or becoming misaligned, or even getting stuck. We'll explore some of these common explanations for why folks get persistent SI joint pain. Because SI joint pain is an affliction that affects lots of folks. Explanations like, this was really common in the yoga community, I'm overstretched from doing too many hip openers, for example. Or there's just a general ligamentous laxity in this individual because they are hypermobile or
00:12:23
Speaker
they're experiencing pregnancy, or the sacrum or the SI joint is misaligned or unstable for various reasons, or also that there is a lack of mobility at the joint. All of these are used as explanations to explain pain. We'll contrast all of this with what current research shows, namely in the way that there is actually a lack of evidence for some of these explanations and research that calls into question their validity.
00:12:51
Speaker
This is actually our second episode on sacroiliac joint pain. In a previous solo episode, episode 21 is the SI joint painful due to instability. I shared my personal experience with SI joint pain in my 30s, coinciding with my yoga practice, which was my sole form of exercise. And then how transitioning to weightlifting notably improved my SIJ pain, like almost immediately eliminated it.
00:13:14
Speaker
and how this whole experience changed my beliefs. That specific issues like my alignment or overstretching in yoga was causing my pain. And you can listen to that episode. It's linked in the show notes to learn how this experience that I had prompted deeper learning and understanding around pain.
00:13:29
Speaker
as well as the importance of exposing my body to more diverse physical stressors to keep myself resilient and feeling good. Yoga was not all I needed. And the role that language, specifically how I explain my pain, largely thinking in terms of my sacroiliac joint being stuck or out of alignment, how those explanations changed,
00:13:49
Speaker
when I experienced almost immediate pain relief by starting to strength train, not by fixing my alignment. In this episode, we're going more into the origins of some of the beliefs I held and that other people hold to better understand where these ideas come from and then to better be able to compare them against current research findings. Throughout this conversation, we're going to be also touring the anatomy and biomechanics of the
00:14:13
Speaker
SIJ with lots of pit stops along the way to discuss the structure's function and perhaps why the structure is not as fragile or weebly wobbly or wonky as it's been made out to be. Sarah, let's have you start. Tell us where is the sacroiliac joint or where are the sacroiliac joints?
00:14:32
Speaker
Yes, there are two of them. So I usually talk about the sacrum as kind of the end of your spine. The coccyx is the tailbone, which is also below that, but I'll describe, like when you take your seat belt and the metal part and you click it into the holder, I visualize the sacrum kind of fitting into the space made for it by the two ilea, the two hip bones, so they can visualize that there is this fitting
00:14:59
Speaker
that happens. It's not sort of all loosey-goosey sitting in there. Nice. And so we can palpate it. I'll talk you through that. So if you find your belly button with your index fingers, both poking into your belly button, then wrap your thumbs around your side waist and just press down a little bit. You're going to feel the crest, that iliac crest. You can start to follow that crest around to the backside of your waist and keep pushing it because it's going to get
00:15:22
Speaker
thicker and more sinewy there with the thoracolumbar fascia being a really thick structure that's overlaying those bones. But if you keep following the top of the iliac crest around, you're going to eventually come to a place where it gets a little harder and maybe a little bumpier. And if you take your thumbs and rub the thumbprint of your thumbs up and down, you might hit up against what's called the posterior
00:15:47
Speaker
superior iliac spine. If you go just slightly medial to that, you're going to probably dip down into your sacrum bone. So that right there marks at least part of the joint or a stretch of the joint between the sacrum, which is central, and the two bones of the ili on the right and left side. The structure and function of the SI joint are vital for transmitting forces.
00:16:14
Speaker
also absorbing shock and providing some amount of mobility. The sacrum is part of the axial body, but interestingly it's also a part of the pelvis or the bony pelvis. So it occupies this really interesting bridge between our axial body and our lower extremities, which is
00:16:36
Speaker
It makes it a place where forces are transferred, right? Like cars across two land masses. Forces are transferred via that bridge, that axial appendicular bridge. Particularly in activities like walking, running, and lifting, where our feet press into the floor, and then the floor presses back up into our feet, and then forces are transferred from the feet all the way up the kinetic chain, through the SI joint, through the spine all the way up to the head. So the sacrum is this key point, sometimes called the keystone. Sarah, do you want to tell us about the joint capsule?
00:17:06
Speaker
Yeah, so surrounding this joint and also all moving joints is something called a joint capsule. It's a collagenous but fibrous tissue that encloses the joint space and basically is part of what makes it stable. But that also means that the two bones that it encapsulates, so
00:17:25
Speaker
the part of the sacrum and then part of the ileum, it means there's going to be some amount of movement there. You don't have joint capsules around joints that don't move. It's not a fused joint. We know that just based on its anatomy. It's not a huge range of motion. I think the measurements are generally, it's something like between three and seven degrees. Yeah, I think five degrees on average. Yeah. Not much. Of a movement that's called nutation and counter-nutation, which is basically
00:17:51
Speaker
It's a sagittal plane movement. It's similar to flexion and extension, in that it moves in the same plane, but it's very specifically describing this small range of movement between the sacrum and the ilea on each side. There's definitely movement available. For people who are like, oh no, it shouldn't move at all, that's incorrect.
00:18:12
Speaker
I mean, if it should move at all, there would be no joint there, right? Right, exactly. I would also say part of the reason why there is movement but not that much is when we talk about the forces going through the pelvis. Ultimately, as ground reaction force, when we take a step, the same forces impacted back through our bodies, one of the goals is to not let that ground reaction force rattle your brain.
00:18:35
Speaker
We have all these things along the way that help absorb it. Some of it is the discs between the vertebral bodies, but some of it is the fact that your sacrum has a little bit of movement to it. It's going to absorb some of the vibration and dissipate it a little bit so that it doesn't go full force up to your brain and give you a concussion every time you go out for a run.
00:18:55
Speaker
Yes, absolutely. And also the pelvic basin has the SI joints, but also the pubic symphysis joint in the front. And this makes it much easier to have a child pass through the birth canal, because now we have softer, more flexible structures that allow the pelvis and the outlet of the pelvis to be able to expand to allow for childbirth. So the SI joint, I didn't know this,
00:19:20
Speaker
officially, officially until I was like reviewing for this episode that it is both a synovial joint and a fibrous joint, which I find really cool. So it has synovial fluid in the part of the joint that is the synovial joint, which I believe is the anterior part of the joint. And then there's this posterior part of the joint that is more fibrous. Fibrous joints tend to not allow for, they allow for very, very little movement. Synovial joints, like your shoulder,
00:19:44
Speaker
are the most mobile joints in the body, generally speaking. So the SI joint actually has two classifications, which I find pretty cool. All right, let's talk about the articular surfaces of the SI joint. Sarah, tell us first, what are articular surfaces of a joint? What is that? So anywhere that you have two or more bones meeting each other,
00:20:06
Speaker
there is a part of each of the bones that is facing the other part. And that's where the movement is happening. And so that's where the articulation takes place of the joint. And so the surfaces are called the articular surfaces. Great. So the sacrum has two slightly concave surfaces called the auricular surfaces.
00:20:28
Speaker
The term auricular comes from the Latin word auricular, which means ear. And in medical terminology, auricular typically refers to structures related to the ear, or ear-like structures, such as the auricular surfaces of bones. They look like ears, I guess. These auricular, articular surfaces of the sacrum articulate with the auricular, articular surfaces of the ilium. Say that sometimes really fast.
00:20:54
Speaker
I don't think I can. These surfaces are covered with cartilage to facilitate smooth movement, but these surfaces are actually really bumpy. Both surfaces, the auricular surface of the ilium, which I guess is also ear-shaped,
00:21:10
Speaker
is bumpy. And then the auricular surface of the sacrum is really bumpy. But what's interesting, if you've ever worked with disarticulated skeleton bones, which I used a lot for teaching, and disarticulated skeleton bones are typically just molds of an actual body's disarticulated skeleton that are cast in hard plastic. And you can get this as a model to use for teaching or whatever you want. And so I have a disarticulated, I actually have a couple of them, and they're the skeletons in my closet.
00:21:38
Speaker
I have several of them in my closet. The bones of the sacrum and the ileum are literally bumpy and rough, but they fit together like a puzzle. So there's one way that they're going to fit together. And so when I was teaching about the pelvis or the SI joint to a group of students, it would take me a while to
00:22:01
Speaker
rub them together to get them to lock and fit. I'm like, oh, there it is. There's the fit right there. And so the reason for that bumpiness is so fascinating, which is that it really contributes largely to the stability of the joint, right? If you have two smooth surfaces slid together, like your seat belt analogy would be like a smooth surface into a smooth surface. Now imagine that seat buckle and the thing that holds it, the sheath, we'll call it the sheath.
00:22:26
Speaker
That they're bumpy inside and so then when the buckle comes into the sheath There's this like locking mechanism that takes place because the bumps fit like puzzle pieces perfectly together and so evolutionarily speaking This is really handy when we went from quadruped to biped
00:22:41
Speaker
where we're now walking around with our trunk stacked up on top of our sacrum and our sacrum keystone into our ilia in this bumpy interlocking fit that now makes it wonderfully stable and a magnificent force transfer hub allowing also this rocky bumpy fit for a multi-directionality of resistance against a multi-directional array of forces that would
00:23:08
Speaker
seek to dislocate our sacrum now, our stymied by this beautiful three-dimensionality of like rocky, bumpy puzzle piece fit. It's phenomenally beautiful design that we have evolution to think. I just got super excited listening to that description. Thank you. It was beautiful.
00:23:26
Speaker
Thanks.
Differentiating SI Joint Pain from Low Back Pain
00:23:27
Speaker
So before we go further into the anatomy, let's talk about SI joint pain, Sarah. I really want to hear from you how you clinically as a PT or how PTs characterize SI joint pain. How is it differentiated from just
00:23:42
Speaker
low back pain, it seems like it all could kind of blur together and be confusing. Oh, for sure. And sometimes people come in with low back pain and SI joint pain, right? So it's not a either or situation necessarily. The same way that I would try to see if there was any sort of mechanical reasoning for low back pain, which sometimes there is, sometimes there isn't, with SI joint pain,
00:24:05
Speaker
I'll do the same thing. My very most basic premise is always that the victim and the criminal are not necessarily the same. If you have SI joint pain, that is the victim of something, it's not necessarily that something is going wrong. In fact, it usually
00:24:23
Speaker
I would say it never is. There's something that went wrong at your sacrum just because of your SI joint and your sacrum, and therefore we just treat the sacrum. I mean, the old model a lot of the time was just what they call chasing pain, right? So for a SI joint hurts, great. I'm going to massage your glutes and your piriformis. I'm maybe going to do a little work in there and see if... I mean, I might still do that, but then it would be like, and you're done. Do some bridges, do some bilateral leg glute work, and call me in two weeks or something.
00:24:53
Speaker
But much more often with the SI joint in particular, and actually it kind of depends if it's one sided or if it's both sides, but very often it's happening because something somewhere else is doing something funky. And like I said, it might even be something like the way that you use your left leg in gait and whether or not you have good big toe push off is then contributing to right sided SI joint pain because
00:25:20
Speaker
The stability right that that sense of okay We're not gonna let the ground reactive forces push all the way up to the brain that let's call it for one of a better word compromised leg Position or musk usage or motor control or any of those things is that forcing something in the sacrum to?
00:25:39
Speaker
take on some of the load and that might be why the pain is happening that's one possible story there's so many varied and possible reasons that someone's gonna have so and a lot of them can be happening all the same time right yeah it'd be like multiple explanations for a single type of
00:25:58
Speaker
pain experience. Totally, totally. So how do you assess whether or not it's SI joint pain versus low back pain? Are there special tests that you do, pain provoking tests that you do? Or is it just a conversation of like point to where it hurts? Well, it's a bit of both. There's generally point to where it hurts. There is a sort of, to me, funny phenomenon where people will tell me they have low back pain and then I'll say, okay, can you point to where you're feeling it? And they point to somewhere on their butt. And I'm like, well, first off, that's not your low back.
00:26:28
Speaker
I don't know if it's that people just don't really know where their back ends and their hips begin or if they feel self-conscious about being like, my butt hurts or whatever. Some of it is just very much, can you show me? I try to avoid as much as possible a lot of the pain-provoking tests because my goal overall with people
00:26:50
Speaker
is to get them to feel like they leave at least feeling somewhat better or at least hopeful that there is a solution to what they're going through. They didn't come to you for you to hurt them. Yeah, exactly. Exactly. I'll palpate a little bit, I'll press slightly, and that's going to give me a really clear indication of where the person perceives the pain to be.
00:27:11
Speaker
And with that, if I'm looking at low back, I'll palpate a lot of things, not the low back. I'll do psoas, iliacus, hip flexors, TFL. I'll look at lateral calf muscles. I'll check out feet. And then if I have them
00:27:30
Speaker
turn over, then I'll look at things like glutes, I'll palpate SI joint on both sides, I'll palpate the iliac crest. I'm just sort of looking all over for like, are there little surprise factors in here that they maybe weren't aware of until
00:27:42
Speaker
we made contact with them and then suddenly it was like, oh, that's really intense. Okay, something's going on here, right? Especially if there's then a differentiation side to side, if I touch the same structure on the other side and it feels fine or not nearly as gnarly, things like that. So I'm not trying again to provoke high levels of pain and it's going to depend on the person in front of me because if the person comes in in like really severe acute pain, I'm not doing any of that stuff. I'm doing all nervous system quieting down kind of work.
00:28:11
Speaker
I'm doing much more gentle massage. I'm doing all that kind of thing. I can't get at the why on somebody who's dialed all the way up to like eight or nine. It's gotta be a little more tolerable before we can really kind of calculate what's going on, in my opinion. Yeah, absolutely. So that's sort of my approach. So in that sense, it's not really any different than any other body
SI Joint Misalignment: Fact or Fiction?
00:28:30
Speaker
part. I would do the same thing for someone coming in with neck pain or shoulder pain. You know, I have certain areas that are like a kind of go-to on my checklist, consciously or not, where I'm sort of looking.
00:28:40
Speaker
And if I can't find anything that kind of jumps out from palpation, because sometimes you can't, then I move into having them do movement. And I'm looking at what movement, you know, either recreates some or all of their pain, or I'm looking at movements that on one side are really functional on the other side are either pain provoking or just incredibly weak. You know, things like that. Awesome. Thank you.
00:29:07
Speaker
Right, so it's probably just very much based on the individual, right? 100%. I'll have categories of things that I'm going to do, but within those like palpation or like movement testing, but within those categories, it's not like, oh, well, I have to test these 10 things and then I have to test these 10 things. It's kind of like, well, what do the results then guide me towards? Well, back to the auricular articular surfaces with sacrum and ilea.
00:29:32
Speaker
Iliad, by the way, plural for Iliad, just FYI, little grammar there, because it's at this intersection, pun intended, the intersection between two bones, that we meet a common claim about why someone has SI joint pain, which is that they have a misaligned sacroiliac joint. And often the reason that it's misaligned, according to this line of reasoning, is that it is unstable, loosey goosey, weebly wobbly, moving around too much, or
00:30:02
Speaker
Iliya are moving around too much or both the sacrum and the Iliya are moving around too much and this excessive movement is leading to joint
00:30:09
Speaker
in congruency between the articulating surfaces. So back to that multi-dimensional puzzle piece fit of the rocky outcroppings of the auricular surfaces and how they fit perfectly together. And this idea of joint incongruency or joint congruency, I hear this term incongruency, congruency used a lot by PTs on social media. And I'm wondering,
00:30:34
Speaker
What's up with this idea of joints being incongruent, Sarah? It sounds like dislocation. I know it's definitely not used to mean the same thing, but what is joint incongruency? How is it different than dislocation? Also, maybe what is dislocation? You shed a little light on how this word is being used, what it's being used to mean. Yeah. Joint incongruency is a fancy way of saying that in that therapist's or whoever's opinion,
00:31:04
Speaker
The joint is not fitting together exactly as well as it could. It's sort of like a little mini step and the bigger step would be the dislocation or even a sub step along the way. Like for a shoulder, for example, shoulders can do something called sublux, which is not a full dislocation, but if someone has a lot of laxity in the joint,
00:31:31
Speaker
that shoulder can kind of feel like it's going to go out, right? It can move more than it should. So congruency or incongruency is a way of just saying, are the two articular surfaces fitting together or holding together in the best possible way that they are supposed to? Okay, how would a therapist measure or assess
00:31:55
Speaker
Whether a joint is congruent or incongruent though, using what tools or way of knowing do they make that determination? Yeah, that's a really good question because it depends on the body part. Also, my understanding is that a lot of the research around it is that you can't especially tell if something is congruent or incongruent. People like a reason. I might say something like this joint is incongruent and then the
00:32:21
Speaker
patient can go home and said, my PT said this joint is incongruent. And that's why it's doing whatever it's doing. In terms of the sacrum, again, my understanding is that the research shows that you can't really palpate how well a sacrum is moving or not moving. It's not something that's consistent. I mean, incongruent is just sort of, it's more of a concept than something like being able to say,
00:32:44
Speaker
your patella has dislocated. Well, you can actually objectively as a therapist see when a joint has been dislocated. Exactly. It's big and obvious. It's probably even for someone like me. For pretty much anybody, that's really obvious. So that's because when you see a joint has been dislocated, correct me if I'm wrong, the bones look funny. They don't look how they're supposed to look. And this is what we could call an observation of the osteokinomatics or lack thereof.
00:33:12
Speaker
Right? So that like the way that the bones are relating to each other, clearly there are problems with this joint. It's a little bit of a like throw up in your mouth moment where you're like, that's not, that looks terrible. With dislocation, the joint is now non-functional. You cannot then go and play basketball on a dislocated shoulder.
00:33:32
Speaker
Yeah, because what's happened is that the osteokinematics aren't going to work because the arthrokinematics have been disabled. Okay, the arthrokinematics is really what we're talking about when we talk about articulating surfaces and the way they interact. So there's a slide, there's a spin, there's a glide type motion happening between these two surfaces, however they happen to be shaped, whether they're concave or convex, right?
00:33:56
Speaker
the arthrokinematics have been disabled in a dislocation. The surface has been pulled away from each other such that now there can be no articulation at the joint, therefore the bones are not going to move, we are not going to see osteokinematic activity, right? What I think happens though, just using logic and knowing how therapists can know things, which is really just using the same tools
00:34:19
Speaker
of observation and maybe some palpation and then also maybe they have x-rays and things like that, which takes it to another level. But you can't look at the way someone moves their arm or you can't look at the way someone moves their thigh and have any idea of what's happening arthrokinematically apart from just generally like big broad brushstroke knowledge of like how those surfaces are probably interacting.
00:34:42
Speaker
But you can't know the specifics of that because you don't know what that joint even is shaped like. Everyone's joints are shaped differently in terms of structural variation. There's different depths, there's different sizes, there's different angles to all of these joints. To your point about not being able to see what's going on at the articular surface, but you're seeing some sort of larger result of whatever the issue might be in terms of the bigger movement of the bone.
00:35:10
Speaker
For example, you might see a scapula that is not going through upward rotation, downward rotation at the same timing or the same amount. But you can't say with any certainty it's because the two articulating surfaces are incongruent.
00:35:24
Speaker
And so this is where I'm going because the reason I want to have this conversation about congruency and congruency, epistemologically, how one would know whether something was congruent or incongruent is in epistemology is like the study of how we know what we
Form Closure and Joint Stability
00:35:41
Speaker
know, right? It's an important piece of this conversation.
00:35:44
Speaker
Because I think it relates very much so to this belief that the reason lots of people have SI joint pain is that they have somehow misaligned their sacrum. The joint is incongruent in some way where those puzzle pieces aren't fitting together correctly.
00:36:01
Speaker
Like if you've ever done a puzzle and you saw two pieces that look like they fit together and you fit the convex end into the concave end and you're like, nope, that's not a fit because there's this big gap over here. It's a little too big or it's a little too small. That's sort of what I think people imagine is happening on an anatomical level that is then the mechanism for SI joint pain.
00:36:24
Speaker
your SI joint is torqued or misaligned. So I want to talk about a very important scientist who probably to a large extent kind of laid the groundwork for this type of unfolding of logic, which it's not an illogical belief to have. It's reasonable to assume that pain would be from some sort of joint incongruency. The problem is, one, how do we know
00:36:50
Speaker
that the joint is incongruent. So we're going to talk about that. But let's actually first talk about a gentleman named Andre Leeming, who focused on the SI joint and the role of ligaments and the way that the bones fit together in order to create what he named and what you'll still hear used a lot to explain this concept, which is form closure.
00:37:14
Speaker
Okay, so we kind of already described form closure, right, when describing the keystone of the sacrum and the fit of the articular surfaces. We haven't talked yet about the massive, incredibly strong ligaments surrounding the joint, and we will in a moment, but this term, I think, form closure
00:37:34
Speaker
was used to explain this concept of there being an incongruency of the interlocking structures that contribute to SI joint pain, suggesting that it's the way the surfaces are fitting together, like puzzle pieces, like ill-fitting puzzle pieces that create this problem. Yeah, I think your description of form closure is exactly right. What I would add is, in pathological cases, we see
00:38:04
Speaker
that there is poor foam closure. So for example, if you have hip arthritis and the articulating surface of the femur and the articulating surface of the acetabulum are no longer even and smooth, but they have been broken down and now you're getting pain whenever you move your leg in a certain way because
00:38:26
Speaker
now the form closure itself has been impacted negatively, but that's a joint pathology, that's a degeneration. Do you use this phrase form closure to talk about all the joints of the body or at least like the hip joint? Is that a phrase that gets applied to other joints? Because I've only ever heard it used in the context of the sacroiliac joint, but is it actually used in other joints as well? I don't really use it at all ever, but I do hear it used as a term to describe any
00:38:55
Speaker
articulating synovial joint. Yes. Oh, interesting. Okay. I didn't know that. That's cool. And so would it be used in a similar way as incongruency? Is it a lack of form closure, a form of incongruency, would you say? Yes. You could use both sorts. Okay, very interesting. All right. But I think where we run into trouble is when it's used to explain pain. What happens is that it gets over extrapolated
00:39:16
Speaker
and that research doesn't actually support some of the extrapolations that are made. Here's my first question. Sarah, how are misaligned SI joints assessed in PT? There's a few ways. Direct palpation of the joint line itself. Joints tend to have a little bit of play, meaning you can push on the joint and move it a little bit as an outside force with your hand. So you'll look for joint play as something that is just naturally there. I can palpate all the way down your spine and find joint play
00:39:46
Speaker
in between each of the vertebrae to their neighbors, right? And you can in some situations feel like, okay, that one's moving, that one's moving. Ooh, this one is not moving. Whether or not, I'm not thinking to point to that and be like, this is the cause of all your pain, but that's part of the story of, to me, that's part of the story of what might be going on with someone. So as far as the sacrum goes, supposedly you can press on one side, press on the other side and tell if they have the same amount of joint play side to side.
00:40:11
Speaker
But then there's also, there's a test, I think sometimes it's called a stork test. It's a standing test where you have one thumb on the sacrum and one thumb on, just underneath the PSIS, the posterior superior iliac spine. And you have the person pick their leg up, go into hip flexion, and you're looking for, is there movement between the sacrum and the ilea? And there, in theory, there should be, right? Because we know that there is about five degrees or so of available movement.
00:40:41
Speaker
And so you can test that on both sides, theoretically. I keep saying theoretically, you know why. Yeah, I know. And then you can assess, OK, is the sacrum moving the way it's supposed to on this side? Is it moving the way it's supposed to on the other side? And draw whatever kind of conclusions you might want to draw from that.
00:40:56
Speaker
I don't remember the last time I did that test, by the way. Well, here's the deal. Tell me what you've heard, but there's, I think, a good bit of research. For example, I'm looking right now at a systematic methodological review on the reliability of these palpation tests where
00:41:14
Speaker
It turns out that therapists are not as good as they would like to believe they are at assessing movement happening or not happening, how much is happening, what direction is happening through their hands. It turns out that palpation is actually not a very reliable way of knowing what's happening specifically at the SI joint. It looks like it's not actually a very reliable way. There's a study by Van Der Werf.
00:41:42
Speaker
that I've linked in the show notes and the conclusion is basically therapists really can't tell if the SI joint is in alignment, out of alignment, if it's moving too much or not enough. If they say that they can, it's probably because they're biased toward their ability to know. But when you look at research when it's tested in a lab, it turns out that they actually
00:42:06
Speaker
aren't coming to the same conclusions, and so there's a lack of reliability. When something has a lack of reliability as a test, it also has a lack of validity. So it's actually not a valid way of assessing SI joint movement. But are there other technologies that are used to assess the movement, maybe in a finer tuned way? I don't know about those, but maybe you do, and if you have anything to add. My feeling is whether
00:42:31
Speaker
you personally are some sort of superstar clinician who actually is very accurate at assessing through your hands or not. To me, it's got a lot more to do with, well, what are you going to do with that information? Are you then just going to go whole hog on the SI and just keep slamming on it and trying to make it move more? Which most likely, in my opinion, is not the source of what's going on.
00:42:52
Speaker
Are you then going to travel a little wider in your investigation and look for other possible sources of what you believe you're feeling? You're pointing out a really, I think, important point of tension between two groups clashing, which is that the
00:43:09
Speaker
group that wants to be hyper-specific and express that specificity with a high degree of confidence will often head down a rabbit hole. And the group that is reluctant to do that will often keep options open, right? And so while it can be comforting to have this specific diagnosis and the specific protocol for treatment, it can also be very misleading because you miss perhaps
00:43:37
Speaker
the forest for the trees in some cases. Yeah. As a PT, my feeling is the worst possible thing that I could do would be to close off doors of possible explanations of what's going on because it might seem that way on first impressions and then the person might come back next week and their body behaves totally differently. I've seen that happen where I'm like, oh, I thought it was this, but now it seems like it's this. So maybe it's near those things and it's some other third option.
00:44:04
Speaker
Yeah, and if you tell them this really specific thing that's happening and give them this very specific protocol, and then that turns out to be wrong, and then you do a 180 and you're giving them something else, that can create confusion. It can create disillusionment, maybe mistrust. It's very easy to get tunnel vision as a PT and be like, this is the thing. I found it. It's what I'm going to put on the eval. It's what insurance is going to pay for. It's what I'm going to treat.
00:44:26
Speaker
I would say it's easy to get caught in that trap as a strength coach and a yoga teacher and anyone helps people as well. So there's another surprising bit of cognitive dissonance that might be inspired by some research showing that actually also ligamentous laxity is not predictive
00:44:47
Speaker
of sacroiliac joint pain because they've done studies on women who are pregnant, who have high levels of relaxin, higher than non-pregnant people, levels of relaxin in their body. Relaxin is a hormone that will soften your soft tissues and make them a little bit more flexible and pliable. And as it turns out, yeah, the
00:45:08
Speaker
This study that I'll link in the show notes confirms that the hormone relaxin does contribute to the laxity of the pelvic joints. That's why it's there, right? So you can give birth, but there's no evidence of relaxin having an effect on symptoms.
00:45:22
Speaker
or perceived disability. So this suggests that the increased mobility of the joints of the pelvis is happening, but it's compensated for, right? So that it's not necessarily going to always produce symptoms. And if it was, every single pregnant woman would have pain.
00:45:41
Speaker
because every single pregnant woman does have relax, and it does have some higher baseline of ligamentous laxity. Here's where we start to trouble this idea that, okay, there's form closure, if the sacrum can become incongruent, which I think is questionable, at least outside of the context of traumatic injury, right? Okay, let's say it can. Is that something we can accurately measure?
00:46:05
Speaker
No, because we can't reliably measure it using the tools that are most commonly used, which is palpation by therapists. But then there's also these huge ligaments holding things into place. And if pregnant women aren't all suffering from SI joint pain that results from their relative joint laxity, then can we logically
00:46:24
Speaker
come to this conclusion that a sacrum that is moving too much or out of alignment is the soul or even the best or even at all an explanation of SI joint pain. It seems like research tends to trouble that
00:46:43
Speaker
way of thinking, which I think has become pretty conventional in terms of how people think about SI joint pain. They're like, well, I must have my SI joint pain is because my sacrum is stuck or overstretched or my ligaments are lax or it's out of alignment. Even if that's true, wouldn't we then see pregnant women in mass all having pain? And then I would say, you know, to your point, it's not the laxity itself from whatever source causing the pain.
00:47:11
Speaker
But for pregnant women, the increased laxity might uncover a lack of stability coming from other structures in the body, like their
00:47:23
Speaker
glute pelvic floor core strength, something like that. It might be that when the stability that they were getting from the ligaments across the sacrum is decreased, they do not have the resilience in their other tissues to make up for it. What does it take to really seriously dislocate a sacrum, Sarah?
00:47:45
Speaker
I mean, have you ever encountered anyone coming to you in the clinic with what looks like a dislocated sacrum? No, because I would send them to the fucking hospital. I don't know why this is, but I often like to talk about people falling out of trees as an example. I don't know how often people really do fall out of trees, but I would say you would have to fall out of a tree
00:48:05
Speaker
like a really big tree and land right on something that then shoved your sacrum. And you know what? Honestly, you'd probably break a bone before you dislocated your sacrum. Someone would maybe have to take a gigantic hammer and just smash you right on your SI joint. It would take an enormous amount of brute force. I think we see it with vehicular accidents. Yes. It's a massive amount of force directed in a really specific way that then causes
00:48:35
Speaker
that kind of dislocation, subluxation or dislocation of the sacrum. And I would say that's not going to happen in a vacuum. That's going to come along with probably broken pelvis or broken femur or broken something else. And yet I was walking around in the, you know, 2013s, 2012s thinking that the way I was aligning my body in yoga poses was, in essence, torquing
00:48:56
Speaker
or throwing my sacrum out of alignment. So if it takes a car accident to dislocate a sacrum. Or falling out of a tree. Why would we, or falling out of a tree? Why would we then think that something as low load as a yoga pose, which is very low load, it's like akin to standing or maybe walking, right? Would be enough to create a minor version of a dislocation, which we could call like an incongruency or a disalignment, right?
00:49:24
Speaker
If it takes so much force to dislocate it, why would so little force slightly dislocate it? Well, I think the conclusion that there's some slight dislocation is just because of the appearance of pain. But again, the appearance of pain is not a one-to-one ratio of, you know, your sacrum is this much incongruent, therefore you're having this much SIJ pain.
00:49:45
Speaker
And yet pain is explained through this mechanism of poor form closure, right? That there has been some movement, some noxious change in position that's creating the problem.
Effectiveness of Adjustments on SI Joint
00:49:58
Speaker
So there's also research on the efficacy of adjustments, right? Something we would see from PTs or chiropractors linked in the show notes showing that also pelvic adjustments do not change the alignment of or improve
00:50:10
Speaker
the SI joint's ability to move, which again, is that because it's not enough force? Is that because it wasn't out of alignment to begin with? Is it because, you know... It might be because an adjustment like that gives off the neurotransmitter dopamine. So you receive some immediate pain relief. And so then the idea is, oh, I put it back into place and now it's not hurting.
00:50:37
Speaker
So the way that pain is explained using these really mechanistic models doesn't really hold up against the evidence or even logic when we take what we know about what it takes to dislocate a sacrum and then extrapolate it out to what is being described as having happened from something like yoga, right? All right, so there's another scientist named Bent
00:51:01
Speaker
Sterison, he's a Swedish orthopedic surgeon who also made significant contributions to understanding sacroiliac joint biomechanics and stability. But he researched more of the intra-articular pressure and muscle activation in achieving the phrase force closure, right? So force closure versus form closure in achieving this concept of force closure. Both Leeming and Sterison were active in the 90s and early 2000s. Sterison emphasized the dynamic nature
00:51:29
Speaker
of sacroiliac joint stability during various activities. So he gives us this concept of force closure. So according to this scientific model, force closure is basically the active stabilization of the SI joint through the tensioning of ligaments. So those ligaments that we're going to describe here soon and the compression of the joint surfaces pressing into each other that is reliant on the tensioning of those ligaments, but also the muscle forces created of the muscles that cross the SI joint.
00:51:59
Speaker
So it implies that both muscular force and ligamentous tension act to forcefully close the joint or hold it together really.
00:52:06
Speaker
and that these internal forces serve to counteract the external forces that would otherwise separate those puzzle pieces if they weren't held together through these force-generating tissues, right? So we have form closure where it's the fit of the bones, puzzle piece fit of the bones, and the weight of the body creating that fit into like the seatbelt sheath, right? But then we have force closure. We have this added
00:52:33
Speaker
Help of holding it all together from these ligaments and muscles. There are several ligaments that reinforce the SI joint Sarah Do you want to tell us about the ligaments? Sarah would you like to name them all? There's a lot of them if you visualize the sacrum
00:52:49
Speaker
And you visualize the two sides of the pelvis, the ilea, where it's fitting into. And you visualize at the bottom of the sacrum is your coccyx, your tailbone. It's a little triangular piece of bone, essentially. And then also your sitting bones underneath you, right? The ischial tuberosities.
00:53:08
Speaker
In essence, there are ligaments that connect and overlap every one of these joints. Your sacrum originally was multiple vertebrae that have fused together. So at each of the multiple vertebrae levels, there is individuality of some of this ligamentous structure. Then there's connection from the tailbone to the
00:53:31
Speaker
ischial tuberosities. There's connection on the anterior side of the inside of the pelvis, as well as on the outside. There's connection between the top of the ilea and the lumbar spine. So it's like if a spider web was actually made out of
00:53:47
Speaker
I don't even know what to say, steel. Yes, exactly. So it's got this kind of overlay of a massive amount of structure, but unlike a spiderweb, you can't just go like and have it go away, right? Yeah, collagen has been likened to steel because of its flexibility and its strength. And all those tissues are made up of lots of collagen.
00:54:08
Speaker
And so ligaments are elastic in nature. They allow for stretch, they deform, they stretch, they lengthen, and then they return to form, which means they're not plastic. They don't stretch and remain stretched. A lot of times, laxity or joint laxity would be used to describe an incongruent SI joint leading to the symptom of pain. But we found in the studies with pregnant women that joint laxity actually is not associated with SI joint pain.
00:54:36
Speaker
And ligaments are not plastic. They don't get overstretched. They can become painful. They can also cause joint pain for whatever reason going on with the ligament. But they are elastic. They return to form. The only exception I would make to this is conditions where the collagen in the entire body is pathological or just not typical. So things like Ehlers-Danlos syndrome.
00:55:03
Speaker
the 14 variations that there are of that or something like Marfan's or any of these other systemic collagen-based diseases is a strong word, but where you might see a lack of strength through the ligaments, but you're also possibly seeing issues with something like detached retinas or other collagenous structures in the body. They're just not able to hold themselves together because they lack that strength. They aren't steel. That's the only exception that I would say. Cool.
00:55:30
Speaker
In addition to ligaments now, there are also muscles that are responsible for forced closure according to this model. And this is where we're going to talk about slings, muscular slings, that create a type of self-locking mechanism.
00:55:44
Speaker
that creates that compressive fit of the joint through the generation of force through these muscular slings. There are three slings, I'll name some of the muscles involved in each, but I think Tom Myers of Anatomy Trains is largely responsible for this concept of muscular slings. So they are the longitudinal sling, which is running along the length of your back from top to bottom, the multifidi, which attached to the sacrum.
00:56:13
Speaker
deep layer of the thoracolumbar fascia, the long head of biceps femoris, which is a hamstring muscle attaching to the sacrotuberous ligament, which is one of the major ligaments of the SI joint. All right, that sling is thought to contribute to forced closure. There's another sling called the posterior oblique sling, which is the latissus dorsi, which runs top to bottom and lateral to medial at a diagonal across the back from the shoulder, like the armpit area, all the way down to
00:56:39
Speaker
the thoracolumbar fascios medially and then runs right into the gluteus maximus muscle on the opposite side of the body, right? And then also the bicep femoris on that opposite side of the body, again, that hamstring muscle that attaches to the sacrotuberous ligaments. So that posterior sling, right? Just imagine like muscles kind of blending into muscles and running like a train, right? Tom Meyers anatomy trains.
00:57:00
Speaker
connected via a fascial web or a fascial network across many joints, but one of those being the SI joint. And that self-locking mechanism being that the contraction of the tension generated through these muscles longitudinal posterior sling, I'll tell you another one soon, is part of what contributes to the force closure of the SI joint. We've also got the anterior oblique sling, where we've got the external oblique, which runs into the internal oblique
00:57:26
Speaker
on the opposite side and then the transverse abdominis creating this crisscross, this X-like kind of, imagine like a big large bandage running from your lateral upper right abdomen down to your lateral lower left abdomen and then the opposite side lateral upper left abdomen running to the lateral lower right abdomen
00:57:51
Speaker
Okay, so these slings, these anatomy trains are thought to be responsible for forest closure. There's actually not a lot of research surrounding anatomy trains or muscular slings and their involvement in pain. But I think anatomy trains or this idea of myofascial slings has given us grounds for creating other ideas around
00:58:14
Speaker
Why we have pain which could bring us to the topic of muscular imbalances right this idea that we have muscles that are too strong or too weak and that this muscular imbalances
00:58:30
Speaker
contributing to some type of structural disintegration right so we need to practice some type of structural integration in order to bring those weaker muscles up to being stronger bring those muscles that are perhaps locked short into being stretched or more open right.
00:58:48
Speaker
And you get approaches to changing really the shape of the body's posture through this approach to changing muscle balances or improving muscle imbalances like rolfing, for example.
SI Joint Pain: Stabilization vs. Mobilization
00:59:02
Speaker
So we've got rolfing, where we're going to
00:59:04
Speaker
you know, do deep tissue type massage on the muscles that are tight or shortened or a needing of release, or other forms of myofascial release, for example, that propose that massage can in some way, shape or form really change the way that our muscles are toned in order to allow our bones to align in a different way. You know, this idea that we can release fascia in a sense to kind of change the way that we hold ourselves, right?
00:59:29
Speaker
If we feel or believe that it's a lack of force closure that's contributing to the problem of us having SI joy pain because that lack of force closure is leading to a faulty form closure, so it's because there's not enough tension or the tension is incorrectly generated in the wrong direction, that because of that we've now got this bad fit
00:59:55
Speaker
this bad form closure, sacrum is out of alignment, torque twisted, misaligned, then clinically, okay, from this line of logic, it would theoretically make sense to choose an intervention to increase the force closure on the SI joint. In other words, to increase its stability, if it's really the lack of stability that's being reason to be the problem, but the opposite also happens. Some people think that it's the SI joint's lack of mobility for why there's pain, right? Because again, the sacrum
01:00:21
Speaker
should be able to move between the ilea. The ilea should be able to move relative to the sacrum. If it's not moving enough, then perhaps, again, we're ending up with this poor fit of the puzzle pieces. So likewise, if that's the case, right, if we've somehow used some tool, hopefully not palpation, because we've already determined that that is actually an unreliable and invalid tool for assessing whether or not something is moving too much or not enough at the SI joint region,
01:00:43
Speaker
We're using some other type of tool, or we're just guessing, right? We guess that somehow it's a lack of mobility. It would make sense then to increase the mobility of the SI joint on one side or the other or both sides or whatever needs to happen. That way, if the SI joint is stuck somehow, we release it. We get it out of its bad position. We free it with, I don't know, mobility exercises or massager or adjustments from a chiropractor, for example. Here's the problem.
01:01:09
Speaker
I'm not sure. You knew I was coming to this, which is that several randomized control trials, linked in the show notes, have found that there is actually no difference between stabilization versus mobilization exercise interventions to reduce SI joint pain symptoms on large populations of people. And actually, several of these randomized control trials showed significant improvement from both types of interventions, neither performing better than the other.
01:01:38
Speaker
Okay, let's back up. Therapists cannot reliably obsess, assess movement, obsess. They can't reliably obsess about a lot of things. They can't reliably get obsessed a lot with their ideas, but they cannot reliably assess movement at the SI joint, which then makes it actually impossible for them to know how someone's joint kinematics, the way the joint is moving, is affecting their pain to begin with. But it also appears that this knowledge wouldn't necessarily need to guide the intervention anyway, since interventions that seek to
01:02:06
Speaker
Stabilize the SI joint that's presumably loosey goosey or weebly wobbly. Work about as well as those that seek to mobilize it. Form and force closure creates a plausible narrative framework for these forms of treatment to make sense until you dig into the research.
01:02:22
Speaker
We cannot reliably measure the form or force closure, and therefore we really can't honestly use that model to predict why someone has sacroiliac joint pain, which is really not very satisfying.
01:02:38
Speaker
Or maybe it's deeply satisfying because of a counterpoint or a different take on that information. What a relief that I don't have to figure out. Is it too mobile? Is it not mobile enough? And instead,
01:02:54
Speaker
I can use the interventions of passive techniques like massage, maybe some joint mobs at other joints that we know we can mobilize, maybe something like laser therapy to reduce inflammation, any of that kind of stuff. And then I can also go in and have people do their active movement interventions because ultimately in every part of the body,
01:03:20
Speaker
one or the other is not enough. You generally need some amount of both. So cool. Now the onus is off of me to decide whether it's too mobile or not mobile enough. I just go in and do all my stuff and get results that way. Do you think that the customer or the patient or however we want to categorize this person coming to receive the service in exchange for money, right?
01:03:45
Speaker
wants to talk to the person who's saying, I just did an assessment on your SI joint, determined that the left side is too loose and the right side is too stiff. And therefore I'd like you to do these exercises to stiffen the left side. And I'd like you to do these exercises to loosen the right side while it were at it. Why don't I do an adjustment on your pelvis? And because of all of this, right, the therapeutic relationship,
01:04:10
Speaker
the fact that the therapist touched them, the fact that there were endorphins released in the adjustment, the fact that now they have a plan of action, they don't feel hopeless anymore, leaves them feeling better. Because there was a high level of certainty and a high degree of specificity, like, tell me what's wrong. I will tell you specifically what's wrong. Oh, thank God. Now I know, right? Versus going to the therapist who's like, ah.
01:04:34
Speaker
you know there's so many things that could be going on here and based on what I see it might be this and it might be that and therefore I'm going to address this one thing with you today and then we'll address these multiple other possibilities over the course of your treatment and I would like you to you know I'll massage you and I'll give you these things to work on but you know I'm not going to tell you specifically what is happening like what do you think is this something you run up against as being like a
01:04:59
Speaker
a clash of approaches in the PT world according to your perspective as a PT, or is it just something that I notice on social media? Well, I have two thoughts. One is of those two approaches, there's then also a third approach where I am treating the way that I would treat, which is not trying to claim one side is stuck and one side is mobile or something like that, but I would build a story that is, to my mind,
01:05:28
Speaker
a more accurate story of what's going on as far as I can tell from all of my testing, my palpation, movement dynamics, things like that. As long as I can come up with some sort of coherent, I call it a story not because it's fiction, but because people want to know the why. So as long as I can come up with a coherent why,
01:05:48
Speaker
I have found that it doesn't matter that much to people whether I'm able to tell them that this side is stuck and this side is not stuck unless they've come to me because someone else has said that to them and they want to know if that's true. It also kind of depends on the personality of the patient. Some patients really want, and honestly, it's mostly my doctors who come in who really want to be able to say, oh, well, I'm having a problem because my psoas is weak. And I'm like, okay.
01:06:12
Speaker
If that's what you think. Oh yeah, so you don't contradict them. I mean, if they ask me, what do I think, then I probably will contradict them. Or I will say, I've never seen something be an issue with just a single structure. So I think you're right, but there's also more to do with it. I've learned in my work, I have a certain amount of energy that I can use during the day. And so I pick and choose where I argue.
Reliability of Muscle Testing
01:06:36
Speaker
very, very specifically. If it's not going to do anything that's going to change my treatment or change the buy-in of the person, then I'll leave it. If they're saying really idiotic things, which sometimes comes in, I might not be like, well, you're an idiot, but I might say, actually, the research does not support that or something like that.
01:06:59
Speaker
Sarah, have you ever had people come in who have received some sort of muscle testing evaluation? Muscle testing is kind of in line with anatomy trains and rolfing in the sense that these are, I would say, popular formats or protocols that are used by clinicians and non-clinicians alike to try to diagnose a problem or get to the root of why someone has pain.
01:07:24
Speaker
Tell us about muscle tests because it does relate to this idea of force closure and then we can also talk about an older idea that might be informative for understanding kind of where these concepts come from about force closure and weak muscles and tight muscles and long muscles and short muscles. Yeah. So the very first semester of PT school, we spent an entire semester in one class learning all of the manual muscle tests that are out there.
01:07:49
Speaker
And the book is Kendall and Somebody. And I had like just PTSD thinking about that book. So some of the tests are for very specific muscles. And some of the tests are for a movement like knee flexion, right, which might take into account a group of muscles.
01:08:11
Speaker
The way that you do manual muscle testing is you put a leg or an arm or whatever into a certain position. You ask the person to maintain that position. You try to, with your own strength, push them out of that position. Based on your interpretation of how easy or how hard it was to move them, you are then going to rate the muscle strength on a scale of one to five. Three being the person can hold their body
01:08:40
Speaker
or withhold that position against gravity. So three and above is generally what you're seeing in outpatient orthopedic people who walk in the door. Lower than that is what you're seeing for people who have spinal cord injury or had a stroke or something like that where they've completely lost function of a muscle for a neurological reason.
01:08:58
Speaker
And then there's this sort of graduated three plus, four minus, four, four plus, as degrees of your interpretation of their strength. And muscle testing is another thing that I don't use it very much, honestly, because
01:09:17
Speaker
it doesn't often tell me something meaningful. Sometimes it does, but most of the time I get much more meaningful information having the person either using red cord or some other thing where I'm having them try to do a movement on one side and then they try to do the movement on the other side and we compare. So movement testing? Yes, versus me coming in and brute forcing trying to make something happen. The two places where I do use muscle testing is, number one, if I'm working with someone who is
01:09:47
Speaker
elderly and I'm going into their home and working on things like sit to stand and getting out of bed and getting out of chair. I'm going to go in and do a very quick, this was what I learned to do in the hospital, very, very quick and general muscle testing routine of their lower legs just to determine is this person, am I putting them at risk trying to get them to stand up or do they possess the capacity to do it?
01:10:10
Speaker
It's very quick and it's very kind of like push here, push here, push here, push here. Okay, here we go. It's really not a possibly hazardous situation. Exactly. And then the other situation that I'll do it is when someone has some enormous amount of pain and or they come in and like I'm thinking about a particular patient I saw recently who came in and was limping.
01:10:37
Speaker
And when I asked them to walk, couldn't, you know, had a foot drop. And this is someone who was like, I'm fine. And then one day woke up and they couldn't really move their foot. Then I'm going in just to see like, is there really that can this person, is there a neurological control of this muscle or a disc that's pressing on a nerve or something like that. And that person I basically was like, you need, we need to, you need to leave here and go get some medical help. I'm not going like, well, your.
01:11:02
Speaker
Glute meat on the left was a four plus, but your glute meat on the right was a four minus, therefore we need to strengthen your right glute. I'm not doing that kind of thing because I don't see the use of it, frankly. It seems like it would be an incredibly unreliable way to draw conclusions about someone's relative strength because it's actually filtering their strength through your strength.
01:11:26
Speaker
Yeah, it's really only useful because insurance companies want to see that change is happening so they'll keep paying for physical therapy. There's zero inter-rater reliability. You and I could test the same person and come up with completely different numbers. We have different strength or sensitivity or we apply force differently. It's a subjective interpretation of the results.
01:11:48
Speaker
The only way it might be useful is in something like where there is a more extreme difference side to side and you're trying to get improvement on one side versus the other, but that's only as long as you personally are applying the same amount of force you did six weeks ago that you're applying now. It's intra-raider reliability, right? The ability to replicate the test consistently yourself, from yourself.
01:12:10
Speaker
Also seems like it would be low and if something lacks reliability it lacks validity you can't have a valid assessment that is unreliable i think that this might often be the case for.
01:12:21
Speaker
Folks who have this idea about why they have SI joint pain is because they perhaps saw somebody who did a muscle test on them and then told them that their right piriformis is weak, or their left lat is weak, or any muscles of these anatomy trains or these slings that are, according to the model of force closure, implicated in this self-locking mechanism.
01:12:43
Speaker
And or have been told that it's because some other muscle is tight or some other muscle is short. I wonder to what extent muscle testing and the conclusions that are drawn from muscle testing also inform these beliefs. Have you ever seen any patients that came in and said like, I've been told my XYZ muscle is weak or tight? Oh yeah, all the time. And also, I'm seeing a lot more people say using
01:13:13
Speaker
the word activated. And I'm always like, what do you, what does that mean? What do you mean activated? They'll be like, well, my, my, this person told me I needed to activate my glutes more. I'm like, well, did you walk in here? Yes. So they are activated. So what do you, the nerve signal is reaching the muscle. Yes. Like you, you are able to stand up. So, you know, have you seen someone who's actually paralyzed?
01:13:37
Speaker
Yeah, this idea of like they're being dead butt syndrome or gluteal amnesia. Yeah, this area is inhibited and so it needs to be not inhibited or this needs to be activated and that needs to be- Right, this is the whole muscle imbalances theory and we can thank Vladimir Junda
01:14:01
Speaker
or Yanda, I believe. I think of Yanda, yeah. Who was active in research from the 60s to the 2000s, who gave us this concept of upper and lower cross syndrome, which at the time was really revolutionary. And so, no shade to Yanda and his contributions to the scientific progress. It's just that these concepts of upper and lower cross syndrome, which are describing muscle imbalances, are outdated and have since been called into question for more.
01:14:28
Speaker
contemporary research. Well upper cross syndrome is typically when there's perceived or thought to be like tightness or hypertonicity of the muscles of the chest and the upper trapezius lifting the shoulder blades up causing a closed chest and then likewise on the opposite side there's weakness of the
01:14:49
Speaker
rhomboids that would bring the shoulder blades together or of the scapular depressors. There might also be, because of this forward head position, a rounded shoulder, maybe a lot of cervical lordosis, like a big bend at the back of the neck, protracted shoulder blades. In other words, bad posture. What we would describe as bad posture up top, and it was thought that this bad posture up top would cause problems like neck pain, shoulder pain, headaches,
01:15:16
Speaker
um you know issues with the upper back things like that uh lots and lots of research has shown that there's actually no relationship let alone a causal one between posture and pain which calls into question how this model of upper crust and was really able to inform how clinicians diagnose and treat
01:15:36
Speaker
their patients, but then there's lower cross syndrome, which I think is more relevant to SI joint pain, which lower cross syndrome involves tightness or hypertonicity in the hip flexor, so they're locked short. So a lot of times the language uses like
01:15:50
Speaker
locked short, locked long. The hip flexors are locked short. The lumbar on the lower back, the erector spinae, are locked short. That is causing too much of a lordosis in the lower back. Then there's weakness or a locked long situation of the deep abdominal muscles and the gluteal muscles.
01:16:15
Speaker
because your gluteal muscles are not posteriorly tilting your pelvis because your pelvis is anteriorly tilting therefore you must have weak glutes and likewise for the rectus abdominis muscles or the deeper abdominal muscles because those muscles aren't posteriorly tilting your pelvis lifting the front rim of your pelvis up so that the tailbone points down that therefore they must be weak and locked long
01:16:37
Speaker
And so all of this, this imbalance leads to anterior pelvic tilt. Oh no, which we talked about in alignment dogma about the pelvis. And so this is sometimes is to explain why people have SI joint pain is because their pelvis is anteriorly tilted. But what problem isn't explained by the dreaded anterior pelvic tilt?
01:16:59
Speaker
I mean, apparently it's the cause of all of my problems. I got a divorce because my pelvis was anteriorly tilted and I lost my job because my pelvis is anteriorly tilted and I have no friends because I have an anteriorly tilted pelvis.
01:17:14
Speaker
you know, upper cross, lower cross syndrome. It is, you know, to your point about how it was like sort of a lot of a new idea at the time, it's also a bit of a don't throw out the baby with the bathwater. Sometimes these muscles are behaving in this relationship to each other. It's just not true that they always are. And it's not true that that's necessarily the source of whatever your pain is. Yeah, exactly. It's not it's not inherently problematic for
01:17:41
Speaker
large populations of people because research shows that that's not the case. But yes, of course, because people are so individual on so many different levels and it's multifactorial and complex, I can absolutely see how these models could be useful just as ways of pattern recognition,
Rethinking Muscle Imbalance Theories
01:17:58
Speaker
right? Yeah. For a way in, let's say you're trying to assess something going on. You might start here and see if any of this is true and you're like,
01:18:05
Speaker
Nope. Okay. Next. Moving on. Right. Okay. So the validity of some of these models, anatomy trains this idea of slings and self-locking mechanism of forced closure, contributing to better form closure and explaining why or why not someone has SI joint pain, but also muscle testing protocols like neurokinetic therapy and others like it. There's also
01:18:32
Speaker
structural integration approaches like rolfing and using massage to release tight tissues and free the structure to align. These have all been called into question by science. In addition, Yanda's models have been called into question by science. Contemporary researchers pointed out where there are gaps, questions, and just a dearth of evidence. So one gap is that these models don't account for the complexity of pain. Research shows that pain is multifaceted.
01:19:01
Speaker
It's influenced by a variety of factors, biopsychosocial, we talk about that a lot.
01:19:06
Speaker
where posture and muscle imbalances may, like you said Sarah, contribute to pain in some individuals, they are rarely the sole determinants. In fact, I learned this while researching for this episode, being able to identify specific patho anatomic causes of low back pain, right? So that's a little different from SI joint pain, but we can use it as an example, like being able to identify specific patho anatomic causes of low back pain,
01:19:32
Speaker
is only possible in about 10% of cases. These formats or these rehabilitation approaches, these proprietary methods, right, contain within them like these big gaps in knowledge. Because here's the thing, pain is a result often of genetics, other psychosocial stressors.
01:19:51
Speaker
individual movement patterns, they can play a significant role in persistent pain. These techniques don't really provide a reliable or valid way of identifying or addressing these factors. They may help in some cases, right? We said, don't throw the baby out with the bathwater, but they have not been studied in a way that could allow us to conclude with any degree of confidence that they
01:20:14
Speaker
help on a population-wide level. There's also questions of efficacy. These approaches lack, again, reliability in that there's a lack of consistency in patterns that we can identify and then be able to extrapolate what these patterns mean for symptoms and solutions, right? So the patterns described in upper and lower cross syndrome do not consistently correlate with the presence or severity of pain. Therefore, muscle imbalances probably don't consistently correlate with the presence or severity of pain.
01:20:44
Speaker
individuals with similar postural deviations may experience vastly different experiences of pain, while others with seemingly ideal posture, and we bring up a lot like the ideal posture of a ballet dancer, may still experience high amounts of pain. There's a dearth of evidence that show that postural correction, which a lot of these are aiming to achieve, lead to pain reduction or prevention. And then there's
01:21:12
Speaker
There's another gap in knowledge, which is that due to individual variability, variation is the norm when it comes to human bodies. While certain postural deviations may theoretically increase biomechanical stress on certain tissues, we also have the ability to adapt to that stress and compensate for that stress and become more robust and resilient to that stress.
01:21:33
Speaker
So what may be considered abnormal posture or movement for one person may be just totally well tolerated, completely asymptomatic for another person. I like Barbell Medicine. I like their podcast. I follow them on social media, their MDs. And they made a post about muscle imbalances or balances. And they wrote unequivocally that we do not have standards for muscle balance.
01:21:57
Speaker
and we lack good evidence correlating supposed muscle imbalances to health or injury risk. The range of normal is vast. We should not make up problems where none exist. How does this relate to SI joint pain? Again, we come back to this idea of there being something called form closure. Okay.
01:22:14
Speaker
that form closure can go awry. Hmm, how do we know what tools are we using to assess that or measure that? Is it true?
Embracing Diagnostic Uncertainty in Therapy
01:22:21
Speaker
Because it takes an awful lot of force to dislocate the sacrum. So it must require at least quite a bit, maybe not as much as a car accident to like slightly dislocate it, which is kind of what
01:22:31
Speaker
incongruency is when it comes to the sacrum, which only allows five degrees of movement on average when standing. We don't have any reliable way of assessing when form closure is going to rise, so therefore then when we start talking about force closure and assessing the mechanisms of force closure and whether or not they're working or not working, like we're running up into these assumptions that we're making about what muscle balance even means. It's not even defined. There's no standard against which to measure it.
01:22:57
Speaker
And then you want to use your body to do a muscle test. So now we're taking this way of knowing that has no standards and no reliability and using it to measure something and make a judgment call on something that also has no standard or reliability. I hope that we can, as people who teach movement, as people who are PTs or chiropractors or however you are showing up to help people, that we can just give ourselves more grace to not have to know the answer.
01:23:23
Speaker
And to know that a lot of the ways that people think they're knowing something are not reliable ways of knowing to begin with. And that to be honest and to be humble is often a really good bet. And that we can rely on certain interventions that have been shown in research to be effective like movement, right? Exercise, pain science, helping people understand pain science and its role in their recovery.
01:23:51
Speaker
While the contributions of Leeming-Sturrisson, Yanda, and others have been significant in advancing our understanding of sacroiliac joint biomechanics, ongoing research continues to refine and expand our knowledge, what that means for how we should help our SI joint.
01:24:07
Speaker
Overall, the SI joint is robust as fuck. It is a tough joint. It is essential for maintaining stability, supporting weight-bearing activities, facilitating proper movement and function of the pelvis and spine, and it has to be so tough because of the forces that endures. Running can put upwards of five times body weight forces through the pelvis, which is a lot more, like five times more than yoga asana.
01:24:36
Speaker
more than more than walking by quite a bit especially if you're sprinting it's a lot a lot more than sitting at your desk or driving your car and these are these are all activities like sitting at your desk too much driving your car too much doing too much yoga these are all used to explain why someone's sacrum would be
01:24:55
Speaker
thrown out of alignment. Well, if it were true that it was like forces that low that could dislocate your sacrum to some extent, make it incongruent or whatever, then we'd have observed a long time ago that running is absolutely disastrous for the sacroiliac joint. Like every runner would be in hospital with a wobbly sacrum. But as far as I know, sacroiliac joint pain is not even in the top 10. The top 10 really involve the foot, the ankle, the knee, the IT band, the hamstrings,
01:25:21
Speaker
The muscles of the lower extremities forces through the foot. An ankle, for example, can be like twice as high as they are for the pelvis. So it just logically, when we start to put the pieces together, we realize that there's just no way that these activities that are
01:25:38
Speaker
Many of them, largely sedentary ones or low force activities, could make a difference in the position of the SI joint. And if they could, man, would we be in trouble. This would be a massive problem. So many people would die from it. If you couldn't tolerate walking, let alone running, walking at least, there's a part of it where you're on both legs and then you're on one leg.
01:26:02
Speaker
with running there's entire periods of time where you have no feet on the ground and then you're loading one side and then the other side and then one side and then the other side and you know if your sacrum couldn't tolerate that
01:26:15
Speaker
I don't think the human race would have made it this far. Absolutely. We would have been taken out by a bunch of tigers much earlier than this. So let's now shift just briefly to what can we do to overcome sacroiliac joint pain? What tools do we have? What is evidence-based? I always go back to movement. And I go back to assessing someone's movement, seeing
01:26:44
Speaker
If their SI joint pain is one-sided, then I'm going to really try to look for, is there some sort of one-sided movement that the person is displaying greater, either sort of motor control of, where all the pieces are lining up and they're doing the movement really nicely, or lack thereof, or is it something where they discover, wow, I had no idea that this was so much weaker than on the other side. And it could be really anywhere
01:27:14
Speaker
through the trunk and through the lower extremity. And the only place that I typically don't go for immediately is neck and head. Although if someone has neck pain, I am checking their sacrum and their pelvis because of the gravitational impact. But I just always come back to
01:27:36
Speaker
you can go get a massage and it'll make it feel better. You can come to me, I'll massage it for an hour. It might feel better for a while, but as soon as you stand up and start moving, we haven't changed your brain's relationship to the muscles and how your muscles are engaging in the act of standing, walking, getting into your car, getting out of your car, all of that kind of stuff. So until we do that, nothing's actually going to change. That's usually what I tell people. When I look back at my own journey to overcoming persistent sacroiliac joint pain,
01:28:06
Speaker
I attribute it to two changes that I made. One was that I stopped making yoga as my only form of exercise and also changed the way I was practicing. So it wasn't so straight lines, 90 degree angles, everything kind of done the same way every single time trying to perfect this aesthetic shape, but became more curvilinear, nonlinear, softer.
01:28:33
Speaker
a multi-planar outside of the confines of those straight lines and sharp angles of the map, but also I started strength training. In starting to strength training, I think what I did was that I impacted my entire system, my body system-wide and increased its resilience system-wide. I didn't just strength train the muscles of force closure.
01:28:59
Speaker
I didn't just go in there and try to make my lats stronger and my glutes stronger. I went in there and I did these four basic movement patterns under significant amounts of low squat, lunge, deadlift, hinge, and push and pull. And over the course of just a couple of weeks, my SI joint pain disappeared and it's never been bad.
01:29:21
Speaker
Amazing. It's never been bad. And it was bad. I couldn't sleep and I was afraid that I really messed my body up permanently, which only made my pain worse, right? Right, right. So, all right.
Reconsidering SI Joint Pain Approaches
01:29:35
Speaker
Hopefully this podcast episode has been helpful. It may have
01:29:42
Speaker
caused a little bit of cognitive dissonance and that's our favorite. Crumbling some bottles of ways of thinking about the SI joint that you've been told and are probably still hearing that may not be supported by evidence and that perhaps there are other ways that we can approach addressing SI joint pain. They're a little bit more general, maybe a little less specific, maybe ways that address the anatomy of your body but also the physiology of your body on a system-wide level.
01:30:08
Speaker
Maybe also this episode has helped you reconsider how you talk about the SI joint and how you think about it.
Conclusion and Podcast Engagement
01:30:15
Speaker
And in conclusion, we hope that you check out our show notes for lots of links to lots of different research papers. I did reference in this episode as well as the link to join the wait list for the bone density course. Get on that wait list to receive the only discount we're offering on the course. We're starting up in October of this year.
01:30:33
Speaker
Finally, thank you so much for joining us. It helps us out. If you do like this episode, if you like what we're creating for you and you want to support us, one way you can do that is to subscribe. Another way is to give us a rating. Five stars, please. Five stars. Review is always that extra mile that we love to read the reviews and then recommend us to a friend who you think would benefit from what we're sharing here. Okay. All right. See you in two weeks.