Sacroiliac Joint Pain – Why is This So Hard To Figure Out?

Dr. Albee set his tools aside and walked to the hand sink for what felt like the 1000th time over the past week. He was exhausted and perplexed. He had just completed his 50th dissection. How could his colleagues make such a mistake? His friends in gynecology and anatomy were unwilling to accept his stunning discovery. Why? What else did they need?

His discovery would explain the unusual pain patterns of women struggling through the final months of pregnancy. Dr. Albee’s colleagues casually tossed the women’s complaints into the “it’s just some back pain” category and told the women they would just have to learn to live with it.

From his studies, Dr. Albee knew they were wrong. He knew the pain these women experienced was from the yet to be accepted sacroiliac joint. He had, for the first time in history, clearly defined that the sacroiliac joint was in fact a true joint with all of the features of other joints in the body including the capacity to produce pain.

The year was 1909.

Now, over 100 years later, Dr. Albee’s work is still misunderstood. When I was teaching at the University of Oklahoma, every student had the same reaction to the topic of the sacroiliac joint. It was a mixture of anxiety, fear, and dread. “It’s too complicated. All those axes, movements, terms, definitions. I just hope I never have to treat anyone who has a problem with their SI joint because I won’t have any idea what is wrong!”

The students’ perception was an accurate one. I still hear it from clinicians today. But consider this – the joint moves only 3 degrees. How difficult can a joint be to understand that moves only 3 degrees?

Why does the SI joint cause such anxiety? Why did the physicians and scientists of the early 1900’s reject Dr. Albee’s findings? Why do people fail to accept the facts and instead accept fiction?

Because fiction is more interesting.

The fiction of the SI joint is that treatment is dependent upon the exceptional palpation skill of the practitioner; without understanding all of the complexities of its axes of rotation, positional changes and unique physical properties, one could not possibly understand what to do.

Hence, practitioners feel quite intimidated by their own apparent lack of knowledge when in fact they know more about the SI joint than they realize. How do I know this? I used to teach manual assessment of the SI joint and all of its complex treatments for many years. Fortunately, the good fairy of reason and common sense came to visit one night and clobbered me over the head. What a relief.

There are two large problems with the distinction of the SI joint as different from other joints. First, the assumption an asymptomatic population will have symmetrical findings and movements. They do not (Dreyfuss et al., 1994). Second, the entire assessment process is highly suspect since one is determining the degree of motion of a joint, that under the best of circumstances, has a maximum range of motion of 3 degrees.

What to Do

Consider approaching an SI injury (a ligament sprain) as you would any other ligament sprain. Do you stretch or mobilize an ankle sprain or a wrist sprain? Generally, no. You protect the area, provide low grade physical stress via specific movements to promote tissue healing, make sure your other movements are optimized (in this case, movement of the hip, knee, ankle primarily), and do your best not to re-injure it (adjusting daily activity is a key area).

I think of the issue like a “stability” problem. Whenever you sprain a ligament, you’re at risk for reduced stability (ever turn an ankle only to discover later on that turning it again is just that much easier?). Stability problems generally respond to stability based programs. And, you can apply “core” exercise concepts to an SI sprain with good results.

Letting go of the need to make something complex when making it simple will do, is liberating and yet sometimes challenging. Treating someone for SI joint related pain is easier when you no longer care which way the sacrum is tilted or whether one ilium is positioned too far forward or back. And, Dr. Albee would be proud.