I just happened to stumble across this fascinating article from Marc Heller, DC, about how he doesn’t think the chiropractic profession adequately manages SI joint dysfunction. (It’s from the 2015 issue of the magazine Dynamic Chiropractic).
I wanted to share it with you all because it echoes some of the same points I’ve made here, about how too many chiropractic adjustments can further destabilize an already unstable SI joint.
Dr. Heller also adds in some additional points about his perspective that I thought were worth sharing as well.
I thought it was really cool that a chiropractor was willing to take a critical look at his profession, and address possible areas where there are room for improvement.
So I’m going to outline his main ideas here, and translate as much of it as I can from anatomical terms to plain English so you can all benefit from what he says.
Ruling out other conditions and causes:
“I think misalignment and pain over the SI area are not enough to make a diagnosis of sacroiliac pain. Pain felt in the SI area can come from many sources. Other joints that can refer pain to the SI area pain include the lumbar discs and the lower lumbar facets. The peripheral sensory nerves, which begin in the upper lumbar or lower thoracic spine, also can become irritated, referring pain to the SI.
Muscle imbalances, whether looked at from a fascial restriction perspective or an inhibited core musculature perspective, certainly contribute to SI pain. Don’t forget the abdominal contents, including the lower digestive tract, and the urogenital system. The pelvic girdle is a great adaptor. When something is stressed in the pelvis or lumbar spine, the SI will twist, misalign and adapt.”
What does this mean?
It means that just because a patient has pain in the area of the SI joints, the SI joints are not always the cause (or there may be a dysfunction there, but something else is driving that dysfunction). The lumbar spine (whether it’s the discs between the vertebrae, or the outlets where nerves exit the spine) can refer, or “send” pain, to the area of the SI joints, and it can be hard to tell the two apart. When other nerves in the back become irritated, they can send pain to the area of the SI joints as well.
Dr. Heller also wants people to look at muscles and fascia (the connective tissue that covers muscles) as potential sources of pain. (The issue of fascia causing pain is a bit controversial, by the way, but more on that debate later).
He’s also pointing out that sometimes, if the patient is having another problem within the pelvis, perhaps with their digestive or reproductive system, the pelvis can sort of shift in response, as muscles tighten up as a protective mechanism. (Again, this may be somewhat of a controversial idea– I’ve never seen this written anywhere else– however it could be the kind of thing that’s true for one in a million patients, but is still true, nonetheless).
Dr. Heller relies on 3 main tools to tell if it’s really the SI joints causing pain:
- Are the SI joint ligaments loose? He uses what’s called provocative testing to see if the ligaments are allowing the joint to move more than it should.
- Does an SI belt help? For some patients, compressing the SI joints helps reduce their pain. (This was never true for me, but I know it is definitely true for a lot of people!). The thing is, he points out, sometimes the belts help for pain that’s coming from the lumbar spine, so it’s not necessarily definitive.
- Are the SI joint ligaments tender to the touch? If they are, this is a good sign that they are irritated and inflamed. Basically, he’s trying to see if there really are local, identifiable factors in the area of the SI joint that are causing pain, so he knows the pain isn’t really coming from the lower back.
If you have a hammer, everything looks like a nail.
Have you ever heard this saying? It basically means that when someone is trained in a certain profession, they tend to view all the problems they come across as something that can be “fixed” by their profession. So when a chiropractor sees a joint causing pain, of course, the first thing they think of is adjusting that joint.
But is that really the most productive approach? Dr. Heller writes,
“If our main tool is the adjustment, we tend to think of all pain as being from something ‘out of adjustment.’ Another problem with our point of view: If our main tool is the adjustment, are we assuming every joint we see lacks mobility. Where are they hypermobile? Where are they fixated or hypomobile?”
This was a problem I encountered, that I now believe delayed my healing. Although my chiropractors were successful in putting my joints back into place temporarily, they (and therefore I) had the mindset that my “cure” was going to depend on adjustments. If my joints moved out of alignment? Go back for another adjustment.
The problem was that, in the long run, this wasn’t enough. I needed to build up muscle strength to take the pressure off of my strained ligaments.
And, it turned out, the adjustments themselves were probably re-spraining my ligaments on a minute level each time.
What really blew my mind is that Dr. Heller brings this up in his article:
“In chronic lower back pain, the pelvis is most often both hypermobile and misaligned. In those cases, we are doing a disservice if we are repetitively adjusting that patient with high-velocity techniques. In the PT world, I see practitioners finding misalignment and repeatedly mobilizing the SI joint. Gentler mobilization may not be doing as much harm – but are you solving the problem?”
My chiropractors were all trained in the Activator technique, which is more gentle than the more vigorous, old-school adjustments chiropractors can do by hand. (This is generally the only form of adjustment I recommend people receive to the SI joint).
But even that was still too much for me. My ligaments were already sprained and stretched, and they just couldn’t take more force.
Muscle Energy Technique
And then, music to my ears, Dr. Heller brings up the Muscle Energy Technique that I love so much! He echoes my point that it can be a more gentle alternative to chiropractic adjustments.
Some food for thought for me, as well as you: reading through the article, I get the impression that there are additional Muscle Energy Techniques for the SI joint beyond what I used.
Somehow I was able to get better only focusing on the forward or backward rotation of hip bones. But there are additional techniques to correct things when the hip bones can move up or down in relation to the sacrum (this is called shearing, or upslip and downslip).
There are also techniques to adjust when the hip bones move out, laterally, away from the sacrum (this is called inflare and outflare).
I have just been learning about these motions recently and am excited to write more about them in the future!
Dr. Heller also addresses the pubic symphysis as an important point to examine (again, everything in the pelvis is connected in one big ring, so if the two SI joints are having problems, it stands to reason that the third joint in the pelvis, the pubic symphysis, can also start having problems).
Dr. Heller has written a bunch more articles on the SI joint.
They are all written in pretty complex anatomical terms, but I wanted to be sure to link to them here in case anyone was interested (and so I personally remember to come back to them later!).
- Sacroiliac Instability: An Overview
- Sacroiliac Joint Correction: A Different Model
- Still More on the Sacroiliac: Basic Principles and Two More Sacral Lesions
- The Sacral Side of the SI Joint: Correcting Anterior and Posterior Torsions
Hope this was helpful! As always, if you have any questions you can email me at firstname.lastname@example.org or leave a comment below! Thanks!