What is SI joint pain anyway?
Do you or your clients have nagging low back pain that seems to be coming from a really specific place in the low back? Is the pain on one side, radiating into the buttocks or at times down the back of the thigh?
Maybe there has been a diagnosis of the generic ‘sciatica’ or a mention of ‘sacroiliac joint pain’. But what exactly is going on in this mysterious condition? Most massage therapists are terrified of the possibility of SI joint problems as they have not even been taught where this joint is, let alone why it could be the cause of pain. Yet massage therapists have a host of skills in their toolbox that can be amazingly helpful in the treatment of this complaint. So read on and be scared of the sacroiliac joint no longer!
Where is the SI joint?
The first step to understanding lies in being clear about where the SI joint is. A big clue lies in the name. The sacrum is the wedge shaped bone at the base of our spine while the ilium is the name of the top part of hip bone (three bones fuse to make the hip bone – the ilium, ischium and pubis). Thus the sacroiliac joint (commonly referred to as the SI joint) is found between the sacrum and the ilium of the hip bone.
To palpate the SI joint on yourself put your hands on your hips as if you are about to tell off a small child. Where your thumbs rest at the back of your body you may be able to feel a small bony pea shaped structure – this is known as the PSIS (posterior superior iliac spine), Feel down a little way from there – just a thumb width or so – and you might feel a slight depression. This is the SI joint. On some folks there are visible dimples in the low back – this is a handy marker for where the SI joint is found. Don’t be hard on yourself if you don’t feel the SI joint exactly – even experienced practitioners have been found to vary greatly in their effectiveness at precisely locating the joint (Holmgren & Waling 2008). As we shall see later this calls into question the validity of some of the tests we use to determine SI joint dysfunction.
Strong ligaments hold the SI joint together but it is still meant to have a very small amount of mobility – but probably only a few millimetres. Pain around the SI joint has been traditionally assumed to be because the joint either becomes too lax or more stuck (hyper- or hypo-mobility in anatomical language). SI joint dysfunction is thought to be the cause of the type of low back pain that comes from around the SI joint, and is often felt on one side only. SI joint pain may refer into the buttocks and down the back and side of the thigh to the knee. On palpation the SIJ and surrounding area may be tender, as may be the sacrospinous and sacrotuberous ligaments, and the pubic symphysis. The person may describe difficulty in turning over in bed or climbing stairs. SI joint dysfunction is also a common diagnosis during pregnancy; it is thought that the increased laxity of ligaments during this time is responsible for this.
Assessing SI joint dysfunction
As the traditional belief is that SI joint pain is due to the joint being too stuck or too loose, there is a variety of manual orthopaedic tests that aim to assess the movement of the joint. For example, here is a common test used to assess whether the joint is stuck:
Procedure: Patient standing or sitting. Palpate PSIS and sacrum at same level. Patient bends forward slowly.
Positive sign: If one side moves higher than the other it indicates hypo-mobility on that side.
There is a host of other orthopaedic tests that aim to ascertain the possible role of the SI joint in low back pain. As therapists we love the idea that we can carry out some tests and come to a firm conclusion – just like a doctor! Clients also trust the idea of ‘tests’ being carried out to determine the exact cause of pain as this fits into the predominant worldview of health and pain that is dominated by the medical model. In this worldview, faulty or misaligned structures lead directly to pain; there is a single cause which if corrected can reduce the pain.
Positive sign: If one side moves higher than the other it indicates hypo-mobility on that side.
There is a host of other orthopaedic tests that aim to ascertain the possible role of the SI joint in low back pain. As therapists we love the idea that we can carry out some tests and come to a firm conclusion – just like a doctor! Clients also trust the idea of ‘tests’ being carried out to determine the exact cause of pain as this fits into the predominant worldview of health and pain that is dominated by the medical model. In this worldview, faulty or misaligned structures lead directly to pain; there is a single cause which if corrected can reduce the pain.
However, more recent thinking and research tells us that not only is pain usually more complicated than ‘faulty structure = single cause of pain’, but also that many of these orthopaedic tests have little validity. This is particularly true if only one test is used to reach a diagnosis. One review of the research studies states damningly, “single manual tests of the SIJ were uninformative”; however, the same study does grudgingly admit that a combination of tests may be more useful. The researchers concluded that: “The usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear” (Hancock et al 2007)
So if you are a practitioner using these tests should you throw them out? Not necessarily, but just be informed about which combination of SI joint tests is the most useful. There is a good research paper by Mark Laslett (2008) available free on the web that summarises the most helpful tests – see the link in the references and give it a read. Also make sure you are not just putting emphasis on the results of your orthopaedic testing as being the last word in the assessment and treatment of SI joint dysfunction. Make sure you are also asking your client about their stress levels, attitudes to pain, levels of activity and exercise and many other factors which we know have just as much influence on our experience of pain.
So if you are a practitioner using these tests should you throw them out? Not necessarily, but just be informed about which combination of SI joint tests is the most useful. There is a good research paper by Mark Laslett (2008) available free on the web that summarises the most helpful tests – see the link in the references and give it a read. Also make sure you are not just putting emphasis on the results of your orthopaedic testing as being the last word in the assessment and treatment of SI joint dysfunction. Make sure you are also asking your client about their stress levels, attitudes to pain, levels of activity and exercise and many other factors which we know have just as much influence on our experience of pain.
So what is going on in SI joint pain?
“The SI joint and TMJ are the garbage dumps of the body” – Jean-Pierre Barrall (visionary osteopath and founder of visceral manipulation)
“The evidence favoring the perspective that mechanical SIJ dysfunctions are related to the experience of back and referred pain is less than convincing, despite the volume of papers published on the subject” (Laslett, 2008) .
So it seems that how ‘loose’ or ‘stuck’ our SI joint is may have less relevance in the phenomenon of SI joint dysfunction than previously thought. For example, the common idea that pregnant women are susceptible to SI pain because of their ligament laxity seems to have little research validity. A study of 163 pregnant women found that: “Increased SIJ laxity is not associated with pregnancy related pelvic pain. In fact, pregnant women with moderate or severe pelvic pain have the same laxity in the SIJs as pregnant women with no or mild pain” (Damen et al 2001).
So it seems that how ‘loose’ or ‘stuck’ our SI joint is may have less relevance in the phenomenon of SI joint dysfunction than previously thought. For example, the common idea that pregnant women are susceptible to SI pain because of their ligament laxity seems to have little research validity. A study of 163 pregnant women found that: “Increased SIJ laxity is not associated with pregnancy related pelvic pain. In fact, pregnant women with moderate or severe pelvic pain have the same laxity in the SIJs as pregnant women with no or mild pain” (Damen et al 2001).
So if the common experience of SI joint pain is not due to these mechanical issues, just what is going on? The pain is certainly real – some estimates suggest that as much as 15–25% of low back pain is SI joint dysfunction (Cohen 2005).
Our own experience in clinic suggests that SI joint pain is often the result of referred pain patterns from fascial restrictions and trigger points.
Fascia is the connective tissue ‘silken body suit’ that permeates and surrounds every structure in the body. We now know that the thoracolumbar fascia of the low back is extensively innervated and may be the source of much low back and SI joint pain (Tesarz et al. 2011). A study by Yahia (1992) also found that two thirds of the sensory fibres in fascia are going from the brain to the tissues. This could also help explain the influence of stressors in the development of low back pain – as we know, ‘top-down’ influences from the brain are just as important as ‘bottom-up’ messages from the tissues.
Trigger points:
Our method of treating chronic musculoskeletal pain at Jing has always relied on accurate trigger point therapy. Trigger points are small areas of tightly contracted muscle that can cause referred pain into and around the SI joint. If you are a bodyworker you will probably have felt them already as they feel like tender ‘knots’ in muscles. There are several muscles that can harbour trigger points that refer pain in and around the SI joint including the erector spinae, gluteus maximus, medius and minimus, quadratus lumborum and psoas.
A multi-modal approach to treating SI joint pain
So for massage therapists, the best approach to treating SI joint pain is through the multi-modal approach to chronic musculoskeletal pain that can be summarised by the mnemonic HFMAST: H: Use of hot or cold. For SI joint pain, heat is generally recommended, although ice should be used in the situation of any palpable swelling.
F: Fascial work around the low back and sacrum area.
M: Treat trigger points in all the muscles around the joint: erector spinae, gluteus maximus, medius and minimus, quadratus lumborum and psoas.
A: Use any acupressure points you know for low back pain. S: Stretches for the muscles treated above. T: Teach and recommend self-care exercises for your client. This could include encouragement to exercise (well known to be a great healer in any pain situations), self-trigger point treatment or any other rehab exercises you know.
A: Use any acupressure points you know for low back pain. S: Stretches for the muscles treated above. T: Teach and recommend self-care exercises for your client. This could include encouragement to exercise (well known to be a great healer in any pain situations), self-trigger point treatment or any other rehab exercises you know.
So in summary, don’t be scared of the sacroiliac joint – your work can achieve a great deal for many clients in pain. CHWAbout Rachel Fairweather and the Jing Institute of Advanced MassageRachel Fairweather is co-founder and director of the Jing Institute of Advanced Massage. An acclaimed teacher and guest lecturer, she has been a massage therapist for 25 years and is author of an upcoming book on advanced massage approaches to be published next year by Handspring Publishing. Based In Brighton, London and Edinburgh, the Jing Institute run a variety of courses in advanced techniques to help you build the career you desire including myofascial courses and a one year advanced clinical massage certiticate. Our short CPD courses include excellent hands on learning in a variety of techniques including trigger point therapy, myofascial release, pregnancy, hot stone and stretching. For the first time you are now able to learn these techniques at your own time and pace with our revolutionary new online courses and webinars.
For the therapist who wants to be the best they can possibly be, we offer a BTEC level 6 (degree level) in advanced clinical and sports massage – the highest level of massage training in the UK.
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