By Brett Windsor, PT
So let’s return to our last case. We spoke about the SI Joint up-slip. We've ruled out serious problems. And we have at least one, if not two, plausible theories from a clinical perspective about what may actually be happening with the patient. We can’t prove either of them, but it’s my contention that this doesn't really matter. Treatment, in a sense, is a method of hypothesis testing. We believe that a problem is caused because of this or of that, and in the absence of examination evidence (which is common) we’ll move forward with experiential treatments based on past successes, and yes, intuition. If the treatment is successful then we’ve defended our hypothesis to a certain extent. If the treatment fails we return to the drawing board. Over time, over the many years and many episodes of clinical experience, we can begin to develop a pretty solid pattern of clinical evidence that supports our intervention when similar patterns repeat.
So let’s look about how we’re going to treat this patient with a lumbopelvic issue...an up-slip? We’ll go with a 40-year old male, slipped on the ice, landed on the right ischial tuberosity, presented with pain in the sacroiliac area with slight referral into the buttock. No radicular pain, but there are significant restrictions of range of motion in flexion, extension, and right side bending, with some relief of pain into left side bending. Pain provocation tests of the SI joint reproduce the patient’s pain - compression, distraction, and a posterior thigh thrust test. We had relief of pain with long access traction and an absence of any neurological signs. There was no sign of the buttock, hip movement was relatively clear with just some pain at the end of range flexion. This all fits a pattern, seen many times in the clinic; there was enough clinical evidence to move forward with a high velocity, low amplitude thrust technique to the sacroiliac joint region on the right. So it now comes down to a choice of technique. My personal favorite is long axis distraction to the right leg in the prone position.
Firstly, we'll educate the patient about their diagnosis, prognosis and management plan so that the patient can make good decisions about their treatment in conjunction with the treating therapist. Once decided, we'll then talk the patient through the technique. We'll explain to them that we’re going to hold the very end range of end of the range of motion and apply a very short, sharp thrust in an axial direction down towards their feet. We'll do our best to explain to them what we think is happening when we do it, and we’ll talk to them about the fact that they may or may not experience a fairly hearty clunking sound - they may feel as though there’s almost a separation in the sacroiliac region. Of course, they may feel absolutely nothing. We’ll set the position up, show them what the position is going to be, walk them through the technique and then back completely out.
Finally, the easiest step in the whole process...actually applying the technique. Permissions have been obtained. Technique has been explained. Background work has been done. There’s no reason not to do the technique here. Patient is prone, upper body relaxed. The right lower extremity is gripped just above the ankle. Hip is in extension, slightly rotated internally. The therapist applies an axial distraction force through the leg. We get to the end of range, hold it there, elbows in by the side and then very quickly pull along the axis of the forearms in a sudden sharp movement down towards the patient’s feet. In my experience, when this technique is successful you’ll feel a deep clunk. It’s not a click like you’ll get in the thoracic spine or the lumbar spine, or even the neck. It’s a deep, thick, resounding clunk. It almost feels, if you’ve watched trains in a yard, it almost feels as if you’re getting shunting of the train cars as they back the engine onto it. They’ll push in and then they’ll clunk together and then they’ll come apart as the train starts to leave. That’s the best explanation I can give it. The patient will feel this. They’ll often be shocked by it, but then here’s how we know it worked. We stand the patient up and if the technique has worked, they will feel profoundly different.
Most of the time, if you've got the diagnosis right, there's an immediate restoration of full lumbar spine range of motion. Flexion is usually completely restored. Side bending too. Often extension is just a little bit, shall we say, unclear at this point; you can usually clean that up with some basic PA's applied in prone. The pain will be gone, replaced by some minimal soreness over the SI joint, which is perfectly natural. There may be some tightness over the latissimus dorsi region and the quadratus lumborum. Straight leg raise will be clear. Hip range of motion will usually be completely restored. Essentially, you've got a patient who feels 95% better.
As indicated, some very gentle prone PA techniques. Five or ten minutes of this and the patient usually has full pain free extension as well. From that point, maybe a little bit of ice over the SI joint if they’re sore, or more likely, I’ll just have them do that at home if they feel like they need it. The instructions then are to continue to extension program over the next two to three days and then to make sure that the hip range of motion is maintained, and then also to give some basic core stabilization around the area to ensure that we get good compression of the SI joint over the coming few days. I’ll then see the patient in two to three days, but I’m careful to remind them that if everything feels fine and they don’t feel as though they need to return to PT, it’s perfectly appropriate as well. Most people are perfectly happy to come up for a follow-up visit, update the exercise program, and then they’re done.
So there you have it. It’s a successful treatment. You don’t see this patient often, but when someone comes in complaining of a fall onto the ischial tuberosity that’s fairly violent and sudden, this is always worth looking at. We've provided a pattern there for you that you can look for, provided a very basic assessment where you can look for some of the main features, but of course always, be very wary of ruling out differential diagnosis that could indicate more sinister pathology. Once the examination is done don’t be afraid to manipulate. This is an aggressive technique. It was an aggressive trauma that caused the problem so you need an aggressive technique to fix it. Now other techniques are certainly possible. You can muscle energy. You can strain/counter strain it. You can probably dry needle it. You could do Astym. You could do Graston. But in my experience, this needs a manipulation. This is one of those techniques that needs to be used in this case in order to affect a full resolution.
So what do you think? I’ve been very honest up front. I do not have papers. I do not have randomized controlled trials to identify this patient population. But what I do have is a solid bank of clinical evidence supported by repetitive patterns of subjective and objective presentation and repetitive success of the manipulation treatment in this case. That’s good enough for me, so when I see this I feel very confident that I can resolve the patient’s symptoms. It’s worth saying that if this problem is not resolved, then within two to three years, it can create problems down the line as the body has to adapt into end range positions to try and restore normal function. So in my opinion this is an evidence-based discussion. We don’t have papers to support it, but we have clinical evidence and we have patient preference to support it. In many cases that’s enough. Don’t be afraid to use it.
What say you?