I could not think of a better title for this article that did not involve profanity. That being said, I want to take a few paragraphs of your time and discuss an often stated, unfounded explanation given to patients as a cause of their pain. The narrative of a rotated hip joint (ilium on sacrum) causing some type of dysfunction is completely unfounded in the literature. I am going to argue this from three points that will hopefully give the reader an understanding of why this narrative is wrong, and potentially harmful to patients.

The ilium and sacrum do not move on a perceptible level

The special tests we have with which to determine movement likely rely on pareidolia

Words have a lasting meaning of patient’s perception of their situation

Moving joints

Continuing education classes and even prominent textbooks utilized in rehabilitation focused schools teach that rotated innominates, nutation, and counternutation are a viable cause of a patient’s symptoms (Magee, Dutton). This is patently wrong. If we look to the literature produced over the last ten years, there are numerous studies that show this to be the case. Nagamoto et al found less than one degree of movement in the SI joint, far below any perceptible level from a clinician.1 Goode et al, in their systematic review, found 8 degrees of movement in the z-axis, 2.2 degrees in the x-axis, and 4 degrees in the y-axis.2 The authors of that paper went so far as to conclude:

“Motion in the SIJ is limited to minute amounts of rotation and translation suggesting that clinical methods utilizing palpation of diagnosing SIJ pathology have limited utility.”

Now, there are two points in that sentence worth expanding upon: 1) the utilization of palpation and 2) diagnosing SIJ pathology. When palpation is studied for the SIJ joint, there are two major themes that emerge: there is a high level of variance within the joint and we suck at palpation. For variance, the paper typically cited is Preece et al from 2008 that found a side to side difference of up to 11 degrees in asymmetry of pelvic landmarks and up to 16mm in innominate height.3 Now, this was a cadaveric study so no inferences could be made on causation for pain, but see point two mentioned earlier – we’ll get there. Up to 11 degrees asymmetry when the joint itself has only been shown to move 8 seems to call in to question the ability to use landmarks to identify a dysfunction. If you will let me channel my inner Billy Mays for a second though, “but wait! There’s more!”. Even with the natural asymmetry, we have difficulty identifying the basic landmarks associated with evaluation. Robinson’s group looked at the reliability of palpation in their reliability study of tests for the SIJ in 2007.4 For palpation they found a percentage agreement of 48% and a kappa of -0.06.

Special Tests and Palpation

One of the main landmarks used in the construction of a rotation narrative is the posterior superior iliac spine (PSIS). It is easy to see how such a large landmark could be useful until there is a realization that you can be on the landmark when palpating in many different places. Cooperstein found a kappa of 0.27 for palpating the PSIS, far below that of any clinical utility.5 Stovall and Kumar, in 2010, took this work a step further by examining the reliability of bony anatomic landmark asymmetry, and found multiple landmarks to possess no good reliability.6

If the joint itself is inherently stable (read: does not move), and we cannot accurately palpate even the largest landmarks, then we cannot keep telling patients rotated hips are the cause of their pain. Even if this were the case, there is nothing we can do about it using manual techniques. Tullberg et al in 1998 (this paper is almost of legal drinking age and could probably use a scotch if it knew the things being said in contradiction to its findings) evaluated what a manual technique does for position of the SIJ using Roentgen stereophotogrammeteric analysis.7 In their study they report being able to pick up less than 0.2mm of translation along an axis using their technique. What they found? Less than a mm of translation along any axis and less than a degree of movement. I’ll go ahead and wait for the “but they didn’t use my technique argument.” Not only does this paper make a case against moving or resetting any joint with a manual technique, via its antiquity, it crushes the argument for clinical practice being 10 years ahead of research evidence.

As for the special tests, most clinicians readily turn to Laslett’s 2008 paper on clusters of tests.8 I would remind the reader of the author’s discussion section:

“The manual therapy literature is awash with books, chapters, and papers on the treatment of the sacroiliac joint. Most of these treatment methods are based explicitly or implicitly on the presumption that some biomechanical malfunction or dysfunction causes either the SIJ or other tissues to provoke the pain of which the patient complains. This hypothesis is fragile indeed, since the means by which such dysfunctions are identified rest upon a flimsy evidential base, disputed by published data showing tests for SIJ dysfunction to be unreliable and invalid.”

Emphasis added.

There are also two papers looking directly at single leg stance and a straight leg raise for detecting motion in the joint showing less than one degree of motion at the joint.9,10 Consequently, using a skill with low utility to identify movement that may be unrelated to pain to determine the correct technique and to detect changes in posterior pelvic position is questionable.

Now, for a quick dive into point two of the conclusions from Goode et al, that of diagnosing pelvic dysfunction. Part of the issue here is we do not have a gold standard with which to determine if pain is originating from the SI joint. Once again I would refer the reader to the paper by Laslett and the distinction made between pelvic dysfunction and pelvic pain. There is no denying that a patient presenting with posterior pelvic pain is actually experiencing pain, what is more in question is how much, or how often the SI joint is the pain generator in the situation. If we look at the base rate of SI joint degeneration in the asymptomatic population, Eno found degeneration in 65.1% of his cohort, with 30.5% presenting with “substantial degeneration.”11 This is not unlike the often cited study showing a high prevalence of herniated discs in the asymptomatic population by Brinjiki.12

If pelvic dysfunction is readily prevalent in the asymptomatic population, it is hard to assign it as the root cause of a patient’s pain. So what are we seeing if special tests lack validity, palpation sucks, and the joints do not move – likely whatever we were trained to see. Pareidolia is the psychological phenomenon by which we see or hear what we expect to see when no true signal exists. The class examples being seeing a man on the moon or Jesus in a piece of toast. If we’re primed to see or hear a stimulus i.e. trained in school via esoteric diagrams of SI movements, many will see those movements whether they are present or not. The class example of this being Merckelback and Van de Ven’s 2001 study in which they had undergraduate students listen to a recording and detect Bing Crosby’s ‘White Christmas’ in which approximately 30% of the students reported being able to hear the song.13 As I’m sure the reader has inferred, there was no song in the noise. How many students, when learning “movement of the SI joint” were looking around in confusion as they were not able to palpate the movement? As the research shows, it turns out there was not any movement in the first place.

It also shows that when you do pick up a signal amongst the noise, it is nearly impossible to not see it again. Some things cannot be unseen. Take the picture below, do you notice anything interesting in it?

If not, you’re among the majority. Unlike the man on the moon or Jesus Christ toast, there is something in this picture staring right at you. There is a cow, staring directly at you. You’ll notice the face along the left side of the picture. Now that you have seen it, you will never be able to look at this picture as noise again. I’m hoping that the above presentation of evidence regarding the lack of movement of the SIJ will have the same effect.

All of this is to bring us to point 3, which is a common theme through many(most) of the Logic of Rehab’s posts.

Words Matter

Telling a patient that their hips are out of alignment, rotated, nutated, in line with Mercury while it is in retrograde, all have the same level of evidence; none . Yet, because of the normal information asymmetry between clinician and patient, they do not know that. To them, you have given a problem (that does not exist) that you do not have a solution to (see prior parenthesis as to why). There has been near constant talk in the literature and on social media recently regarding the role of placebo and nocebo, and there is mounting evidence that clinicians unknowingly often have a nocebo effect.14,15 Simply rewording an MRI has been shown to contribute a positive effect on patient’s perception of their condition.16 Imagine the effect of rewording a clinical examination narrative eliminating fairytale problems like rotated hips or adhesions. Arthur C. Clarke is credited with the quote “magic is science we don’t understand yet.” I would argue the same could be said for placebo and nocebo effects, but we are gaining an understanding at an increasingly rapid pace. This is why the argument has been made for a transition away from placebo and nocebo and towards contextual effects.15,17

The more we gain insight into the subtleties of what we as clinicians are doing, the more we can harness the effects of therapeutic alliance and clinical equipoise.18,19 Each of these factors, in their own right, can sway the outcome of a treatment. Therapeutic alliance is the relationship formed between the healthcare provider and the patient, or getting to be on the same team. Just like a coach cannot be the one on the field influencing the game, the role of the provider should be encouragement, not a constant narrative of negatives. The coach is not allowed to step on the field to intervene with the game. With the amount of coaches/rehab specialists on social media offering ways to “fix hips” or posting videos of moving a hip model with rubber bands for joints you would think the “game” is only played by them, and not those experiencing pain.

Clinical equipoise is how much the provider believes a treatment is going to work. That belief alone has been shown to influence outcomes, even if the intervention is inert.20 How much of the current effect of interventions based on the narrative of hips being out of alignment is based on equipoise is hard to say, but it certainly plays a role. We cannot continue to support the positive belief that our interventions are working at the expense of instilling a negative belief in patients that there is something wrong with them. This is all predicated upon the narrative attached to the diagnosis, prognosis, and intervention. The diagnosis, from the perspective of the contribution of the SI joint to pain should not include the narrative of hips rotating or being out of alignment as that is entirely unsupported in the literature. The prognosis should serve as a positive reminder to patients that they are likely going to get better, and they are ultimately in control of their situation. The narrative of the intervention should never include an immediate changing of local tissue structure. Patients should not feel they need for us to fix them. We are ultimately facilitators, not mechanics. Our job, like that of a coach, should be to guide the path, not play the game.

So, next time you feel compelled to tell a patient their hips are out of alignment, please realize the only thing actually out of alignment is your worldview with the current body of literature.

As always, if you want to discuss the article with us on Twitter, or just recommend a beer for us to try you can find us at:

@DMilesPT

@MichaelRayDC

References:

Nagamoto et al. Sacroiliac joint motion in patients with degenerative lumbar spine disorders. J Neurosurg Spine. 2015;23(August):209-216. doi:10.3171/2014.12.SPINE14590. Goode A, Hegedus EJ, Sizer P, Brismee J-M, Linberg A, Cook CE. Three-dimensional movements of the sacroiliac joint: a systematic review of the literature and assessment of clinical utility. J Man Manip Ther. 2008;16(1):25-38. doi:10.1179/106698108790818639. Preece SJ, Willan P, Nester CJ, Graham-Smith P, Herrington L, Bowker P. Variation in Pelvic Morphology May Prevent the Identification of Anterior Pelvic Tilt. J Man Manip Ther. 2008;16(2):113-117. doi:10.1179/106698108790818459. Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S, Telje T. The reliability of selected motion- and pain provocation tests for the sacroiliac joint. Man Ther. 2007;12(1):72-79. doi:10.1016/j.math.2005.09.004. Cooperstein R, Hickey M. The reliability of palpating the posterior superior iliac spine: a systematic review. J Can Chiropr Assoc. 2016;60(1):36-46. http://www.ncbi.nlm.nih.gov/pubmed/27069265%5Cnhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4807681. Stovall BA, Kumar S. Anatomical Landmark Asymmetry Assessment in the Lumbar Spine and Pelvis: A Review of Reliability. PM R. 2010;2(1):48-56. doi:10.1016/j.pmrj.2009.11.001. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint: A roentgen stereophotogrammetric analysis. Spine (Phila Pa 1976). 1998;23(10):1124-1129. doi:10.1097/00007632-199805150-00010. Laslett M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. Man Ther. 2009;13(3):124. Kibsgård TJ, Røise O, Sturesson B, Röhrl SM, Stuge B. Radiosteriometric analysis of movement in the sacroiliac joint during a single-leg stance in patients with long-lasting pelvic girdle pain. Clin Biomech. 2014;29(4):406-411. doi:10.1016/j.clinbiomech.2014.02.002. Kibsgård TJ, Röhrl SM, Røise O, Sturesson B, Stuge B. Movement of the sacroiliac joint during the Active Straight Leg Raise test in patients with long-lasting severe sacroiliac joint pain. Clin Biomech. 2017;47(May 2017):40-45. doi:10.1016/j.clinbiomech.2017.05.014. Eno J-JT, Boone CR, Bellino MJ, Bishop JA. The Prevalence of Sacroiliac Joint Degeneration in Asymptomatic Adults. doi:10.2106/JBJS.N.01101. W. Brinjikji, P.H. Luetmer BC. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Population. AJNR Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.Systematic. Merckelbach H, Van de Ven V. Another White Christmas: Fantasy proneness and reports of “hallucinatory experiences” in undergraduate students. J Behav Ther Exp Psychiatry. 2001;32(3):137-144. doi:10.1016/S0005-7916(01)00029-5. Setchell J, Costa N, Ferreira M, Makovey J, Nielsen M, Hodges PW. Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey. doi:10.1186/s12891-017-1831-7. Testa M, Rossettini G. Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes. Man Ther. 2016. doi:10.1016/j.math.2016.04.006. Bossen JKJ, Hageman MGJS, King JD, Ring DC. Does rewording MRI reports improve patient understanding and emotional response to a clinical report? Clin Orthop Relat Res. 2013. doi:10.1007/s11999-013-3100-x. Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskelet Disord. 2018;19:27. doi:10.1186/s12891-018-1943-8. Bishop MD, Bialosky JE, Penza CW, Beneciuk JM, Alappattu MJ. The influence of clinical equipoise and patient preferences on outcomes of conservative manual interventions for spinal pain: An experimental study. J Pain Res. 2017;10:965-972. doi:10.2147/JPR.S130931. Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain. Cook C, Sheets C. Clinical equipoise and personal equipoise: two necessary ingredients for reducing bias in manual therapy trials. J Man Manip Ther. 2011;19(1):55-57. doi:10.1179/106698111X12899036752014.