Movement Patterns and SI Joint Pain

I have written previously about my belief in the error in practicing motion palpation surrounding the sacroiliac (SI) joint (see: Time to Let Motion Palpation Die?.)  A new paradigm of assessing motion of the SI joint was first introduced to me in the work of Richard Jackson, PT, OCS and Kris Porter, PT, DPT, OCS in the Pelvis and Sacroiliac Joint section of the Current Concepts of Orthopedic Physical Therapy guide.  Jackson and Porter describe that in light of the unreliable nature of assessing SI motion with palpation another manner of mobility assessment is desired.  One test suggested, while admittedly empirical, is a modified version of the Stork Test.  Traditionally, the stork test is performed by palpating the tested innominate’s PSIS and just medial to the PSIS of the same side.  The patient then flexes the hip of the test leg to 90 degrees while the pracitioner palpates for SI motion, with a normal finding said to be a inferior displacement of the PSIS.  As referenced in my article linked above these motion palpation tests are both woefully unreliable and invalid.  However, the modified Stork test, while not yet researched presents to me with better face validity.  Aberrant gross movement patterns are easier to identify and the evident, anatomical rationale implicates possible SI joint mobility restriction/ SI dysfunction.  During the modified Stork test, instead of placing the thumb on the PSIS you simply place your hands on each hip over the innominate bones.  The patient then again flexes the hip, allowing the knee to remain relaxed and flex as well.  A normal, or negative, test would show concomitant hip flexion with innominant posterior rotation, sacral extension, lumbar flexion, and slight spinal rotation towards the flexed leg.  With the negative test the hands will follow the pelvis into this normal posterior rotation without any compensations not listed above.  A positive test, however, will show a ipsilateral hip “hike” as the hip flexes as a hypomobile SI joint will not allow the posterior innominate rotation.  This presents as potentially more reliable as the “hike” is more easily observable than trying to feel with the thumbs the tiny movement at the SI joint.

Assessment of lumbopelvic rhythm is also suggested as a method of movement pattern observation lending some insight into sacroiliac joint dysfunction.  A normal lumbopelvic rhythm is traditionally said to occur with 120 degrees of motion, 60 from hip flexion and 60 from lumbar flexion.  Jackson and Porter site van Wingerden et al(2) who found individuals with pelvic pain had impaired forward bending.  Therefore, the observation may imply that those with pelvic pain will utilize a more spine dominant movement pattern and/or limited hip flexion during forward bending than those without pain.  It has also been demonstrated that individuals with pelvic pain will exhibit anterior rotation relative to the sacrum on the stance leg during single leg stance(Jackson and Porter.)  This has been described as a faulty movement strategy implicating faulty stabilization for load transfer.

I am note fully espousing these presented tests, however, I am suggesting that they show more promise than the antiquated and invalid idea of assessing and correcting postural flaws (rotations, upslips, downslips.)  The notion of using movement patterns to assess dysfunction is more encouraging as we know these gross movement patterns are more easily observed, although I fully disclose that these methods of assessing SI joint pain have not been validated.  It should be clear that these tests can reveal asymmetry in motor control and local and global muscular dysfunctions which can then implicate the tests as being, to an extent, both diagnostic and prescriptive.  If a patient shows movement pattern aberrancy during the modified stork test then we could conclude that exercise programming should eventually lead the patient towards the ability to stabilize the lumbopelvic girdle to promote the dysfunction in hip flexion.  While the exercises to accomplish this may be a bit more obscure and nuanced than this suggests, it still provides principle to treatment philosophy.

 

1.  Jackson, Richard, PT, OCS, and Kris Porter, PT,DPT, OCS. “The Pelvis and Sacroiliac Joint: Physical Therapy Patient Management Utilizing Current Evidence.” Current Concepts of Orthopaedic Physical Therapy. 3rd ed. APTA.

2.  van Wingerden JP, Vleeming A, Ronchetti I. Differences in standing and forward bending in women with chronic low back or pelvic girdle pain: indications for physical compensation strategies. Spine. 2008.

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Author: Landon Booker, PT, DPT, CSCS

I am a doctor of physical therapy and strength and conditioning specialist practicing in an orthopedic and sports medicine physical therapy clinic in Omaha, Nebraska.

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