Hi everyone!
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.
Main Points:
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.
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
Ultimately, I thought it was really cool that Dr. Heller was willing to go out on a limb and address the shortcomings of his profession this way.
His points happen to line up exactly with what I’ve learned through my own experience, so I wanted to be sure to include this here.
What do you guys think? Have you tried chiropractic adjustments, but found you’re still having issues? Let me know in the comments below!
My Sacroiliac Joint Saga 
Great points! I strongly believe that some Chiro adjustments can do more harm than good. When it comes to disc herniation, adjustments may be an optimal route, however if it’s an SI issue, you likely would be better off with a less aggressive approach. I found that whenever I “popped” or “cracked” my pelvis area joints, to get a little relief, I always paid the price later on in the day; usually hours after. Recently, I’ve implemented about 5 sets of the hip abductor machines at my gym, which has had me feeling great. I believe most gym have the hip abduction machines so doing 5 set on each has helped me a ton. Also, doing the knee-to-chest stretch immediately upon waking helps a lot too (thanks, Christy!). Lastly, doing VERY controlled core exercises and cobra stretches have also helped. I noticed if I went an inch too high or if I lost contraction that would yield a “pop” and I would have a shooting sensation for about a minute or two. Overall, I still believe folks will recover differently, but the cracking and popping is a no-no for me.
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Hi Alex, thanks so much for your comment! I think you brought up a lot of things other readers are going to find helpful, as well. That’s great that you’ve been able to pinpoint some of the things that make you worse, and the things you can do that help! Although everyone’s body is different, I think that beginning to identify these things is really the first step for each of us.
I find it really interesting that the cobra stretch helps you, but only within a certain range of motion. And it’s a really good sign that you’re able to identify this– it means you’re definitely succeeding in getting in touch with your body.
Glad the knee to chest stretch is helping, as well! This all sounds really encouraging!
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Such good information! This explains why my pubic bone was raised when I was examined by a physical therapist. I am having problems with both SI joints – they seem to be taking turns on which one is stuck.
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Mine takes turns as well. It started on the right side and goes back and forth. Currently, it’s on the left side but that could change tomorrow…
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Hi Gail, glad you liked the post! Yes, the pubic symphysis can definitely be a factor in SI joint dysfunction. I’m really glad your PT was able to identify that it was out of alignment– I think it can be hard enough to find someone who knows how to examine the SI joints, let alone the pubic symphysis.
And yes, my SI joints would also take turns on which side was “stuck.” It could be one side that was always stuck for a month, but then, all of a sudden, something could make it switch. (Things like driving over a pothole that would shake the whole car, or getting a massage where the therapist pushed down too hard on my lower back). Then, the new side would be the side that kept getting “stuck” for a month or so.
Luckily, I was able to stabilize both sides in the long run, by focusing on building muscle strength on both sides equally (and, of course, the core!).
Glad you found the article helpful!
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I looked through them, and I didn’t see anything about a joint that’s hypomobile without being “fixated,” which is the word Dr. Heller uses. Instead, he writes “trauma to the pelvis or lower extremity can leave overstretched ligaments and/or may predispose the patient to pelvic problems. In chronic lower back pain, the pelvis is most often both hypermobile and misaligned.” (This is in the article I referenced at the top of the post).
In fact, Dr. Heller writes that when the muscles around a joint are spasming and making it appear hypomobile, it may be that they are actually protect a joint that is unstable, or hypermobile.
“Don’t be fooled by the hypertonic muscles. The tight muscles are often compensating for the lack of joint stability, and lack of deeper core tone and function. An unstable, hypermobile sacroiliac is often surrounded by hypertonic buttock and lower back muscles.”
(Hypertonic means a muscle that has more muscle tone than average– aka is contracting constantly without relaxing, as in a muscle spasm).
Hope this helps! From his articles, I get the sense that he thinks SI joints can either be hypermobile or “stuck”/fixated… but not hypombile but still in alignment.
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Has anyone had cranio sacral therapy for SI? I am scheduled next week. I injured myself in a fall while roller skating last Jan and it took me many months to figure it out on my own that I had popped (yes I felt it) my SI joint and not my L spine. Since I’m an RN, I’ve taken a “wait and see” approach to this injury as opposed to immediately having tests and treatments. I declined a PT referral from a doc when she and I weren’t sure what the issue was (I’ve worked in rehab- you can’t rehab an injury when you aren’t sure what the injury is). Now that I know, I would gladly skip it along with chiropractic (I’m sorry but some find DOs quacks but I’m of this mind with chiros). I’ve been holding it together mainly with high dose curcumin, boswellia and ginger along with a very strict anti inflammatory diet (my educational background is in clinical nutrition and I worked in the field 10 years- sold supplements in college for years so I’m quite familiar). The hip belt appears mildly helpful but I can’t function without the supplements or my left SI joint and entire sacrum becomes inflamed. I have lived on ice packs and heating pads since March of 18 with a remission of symptoms (supplements only) all last summer that came back with a vengeance in the fall. Going to try CST and just bought insoles for my shoes. The pool is next since I can no longger tolerate any of my former exercise routine and am now losing muscle tone.
The moral of my tale is don’t roller skate at 44 even if you feel you are in awesome shape (your muscles may be but the rest of you is indeed aging and won’t bounce back like your 10 year old!)
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Hi Lisa, that’s really interesting! I personally never came at this through a nutrition angle, but now I wish I had!
I never pursued craniosacral therapy myself, because the one time a massage therapist offered to perform it on me, I had concerns not about the placement of her hand under my sacrum as I was lying down. I had sort of learned the hard way to avoid having anything that prevented my weight from resting symmetrically. However, CST was not her main specialty by any means– maybe you will have a totally positive experience with the person you are going to see!
I would definitely suggest PT now that you do have a clear idea of what the issue is. It definitely takes some searching to find a good PT with experience in treating the SI joint (not all of them will have it). But once you find the right person, they can really be instrumental in assessing your pelvic mechanics and helping to correct any imbalances, using gentle techniques such as the Muscle Energy Technique (which I swear by!). It’s much gentler than chiropractic adjustments.
You can find out more about my experience (and what it took for me to finally find the right PT, which was quite a process!) in these posts: https://sijointsaga.com/physical-therapy/
Hope this helps!
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Hi Christy,
I’m speaking to you from Spain. Here the ignorance about SI is very big.
I have had bad luck, thinking that some chiropractor could help me. After 4 months of adjustments they have created me hypermobility and now I’m pretty bad.
At the moment I am using a SI belt, it is helping me.
Your blog is formidable, you are a great help for those of us who are lost in this problem. I have seen that you have healed with MET, self adjusting your joints. You recommend going to a good physiotherapist. I live in Barcelona (Spain) and I do not know where to go. Can somebody help me ? Is MET the same as Muscular Activation Technique (MAT) ?
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Hi Trini, I already answered you in the discussion group, but for anyone else who happens along this page– Muscle Energy Technique and Muscle Activation Technique are not the same thing. However, you can look for a physiotherapist near you by searching for Tecnicas de Energia Muscular– that’s how you say Muscle Energy Technique in Spanish.
And, In French, it’s Techniques d’Energie Musculaire.
Hope this helps!
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I had an L5-S1 discetomy back in 2007. Was told by my surgeon that he thought I had a form of spina bifida, tho I never knew. Never had a problem since my surgery. It was a great success.
In 2017, while going to a Chiro for my neck, he decided to adjust my SI joint. Within 2 days, I could barely walk. I didn’t feel stable like my trunk would fall off my legs. Pain like I’ve never experienced. Legs went numb a couple of times. There was immense pain in my groin and continues 3 years later.
I have to be on high doses of Etodolac to be able to move and walk.
What on earth could’ve happened?
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Hi Monica, I’m so sorry to hear about this. I also had a strange reaction to a chiropractic adjustment once, where I felt unstable and couldn’t walk normally, although thankfully in my case it turned out to only be temporary. https://sijointsaga.com/2018/05/22/chiropractic-risk/
I would suggest pursuing the spina bifida diagnosis more. I think there may be some kind of connection here, in terms of why you would have this reaction.
Since I wrote this post, I myself have learned that I have a genetic condition as well (hypermobility) and I believe that is likely part of why I had the pronounced chiropractic reaction that I did. In general, I think that when you really find the right specialist with experience in your specific issues, a lot of things can become more clear.
I hope this helps!
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Hi I have been diagnosed with a L4 L5 Herniated (confirmed by MRI). Orthopaedic surgeon and PT seem focussed on this but I know the pain sounds more like the sacro iliac joint issue.
Unfortunately I fear this issue has been caused by the chiropractor I went to for the herniation. In comparison to the pain I have now the disc pain was mild. He performed some horrific forceful movements after which I had immediately to go to Dr to get strong pain relief.
It so confusing and I’m so disheartened and weak by 4 months being housebound. Where can I go to get help? I live in the UK.
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Hope you get answers. I had L5-S1 surgery 13 years ago and was doing just fine until I saw a chiropractor for my neck. He decided to adjust my SI joint for some reason and I’ve been a mess for 3 years!
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Hi Ruth, I’m so sorry about everything you’re going through. I do keep a directory of reader recommendations. So far I only have two people listed for the UK, but I have heard great things about each: https://sijointsaga.com/physical-therapist-and-doctor-directory/
In general, I really recommend working with an experienced physiotherapist who can perform hands-on adjustments. I offer more tips on how to find someone with the right training here: https://sijointsaga.com/physical-therapy/
I hope this helps! I also offer coaching calls if you ever wanted to check in for more personalized recommendations (and moral support!). You can find more info here: https://sijointsaga.com/2020/02/25/i-am-now-offering-coaching-calls/
Hope this helps!
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OK,like ohhhhh 15+ years of injections by medical doctors, and also later at year 10 or so Chiopractor told me no wonder you are in pain…you have scolossis(spelling??) and have since also continued with medical doctors and chiopractor (who is really good) but this last year I quit going to all and I have had to walk in severe pain like the Hunchback of Notre Dame……and finally went to medical pain doctor, he burned my facet nerves on L & R and as a result the SI left side started hurting so evidently the pain on the left was the si joint ….facet RFA’s maybe not needed…..anyway, back with Chiopractor agai, using laser, ultra sound and drop movement and also trying Dry Needling. I have noticed over all the years I have had bowel movements symptoms and none or actually right now this past couple of weeks, going easily….with minor constipation….I have started using those mobile carts when I go to big store for shopping….or have to go and sit in car when pain attacks. Trying to keep using my legs for walking and keeping away from having to use carts for future mobility. Sitting is absolutely no pain, minute I get up the left side get ok but then again very painful and have to sit down like when I go to mailbox (live in country) and take a sit down on way back to ease pain. Talk about frustrations!!!! YES YES YES!!!
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So sorry you’re going through this… I personally think the best course of treatment is physical therapy, although it has to be with the right person. More info on this page: https://sijointsaga.com/physical-therapy/
I really hope you’re able to find some relief soon!!!
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Thanks enlightening . Going to try pool leg hang for low impact therapy coupled with triton traction bed stretch therapy more pool work tho. See how it goes.
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I think hypermobile SI Joint, when it is very bad, and you have tried every which way to mend it, fusion is the way ahead.
CW
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