This opinion piece is written by Brendan Mouatt. Brendan is practicing Accredited Exercise Physiologist in Melbourne, Australia. Through The Biomechanics Education he runs musculoskeletal courses and exercise based therapy courses for health practitioners. He teaches at Victoria University, is a Credentialed McKenzie Spinal Therapist and has a Diploma of Clinical Pilates.
Not a day goes by where I don’t see a client who reports that their hips are “out of whack”, they have one leg shorter than the other causing their back pain, or they are putting up with pain because they have scoliosis. And not a day goes by where I won’t challenge them on these concepts (where appropriate). Clients don’t come to these conclusions without their health care professionals putting these notions in their head. We will explore the evidence behind hip assessment and where communication and clinical reasoning play a vital part in improving patient prognosis. Before we start, let me ask you this;
What benefit does the client gain from being told that their hips are out of "whack"/have a "pelvic torsion"/have a "leg length discrepancy"? Will this lead to more optimal outcomes? No, it won’t, how would it? The only thing that tends to benefit is the ego of the practitioner -- how clever do we feel evaluating their body and pulling apart all of their imperfect intricacies?
I saw a client a few weeks back, let’s call her Tracy. Tracy is a Pilates instructor. Tracy loves what she does and whilst ensuring to keep up to date with her personal development she attended a musculoskeletal pelvis course run by an allied health professional (the specific profession isn't irrelevant). Tracy learned all about Gillet’s (or the stork) test, she learned basic manual muscle testing (MMT), and she soon learned that she had a pelvic torsion. Due to this, Tracy had a leg length discrepancy, a weak left glute, weak transverse abdominis, overactive hip flexors, and a lot of activation/timing issues in need of correction. Tracy was keen to have all of this rectified. Fast forward to the day she attends our consultation room for her first session.
“So, that’s a fair bit of stuff going on Tracy, how does this affect you on a day to day basis?”
“Ah, I’m not sure what you mean?” Tracy replies
“Well do you have any pain or discomfort; does it stop you doing anything?”
“No, but my hips are out…” she reinforces.
Are you starting to see an issue with this?
We assessed all functional movement, did MMT, special tests, assessed her spine and talked about her beliefs. Within that one session her range of motion restrictions, her leg length discrepancy (minimal if anything) and her pelvic torsion (minimal if anything) were rectified through restoring one specific lumbar spine movement. She walked out – still – pain free.
What made the session truly challenging was all the BS I had to de-threaten. If left any longer her beliefs may well and truly have manifested into real issues, whether that be fear avoidance or the sensitivity that comes with the cognitive expectation of pain and dysfunction. Doing this tactfully without depreciating previous professional opinions was difficult to navigate, but something I considered of upmost importance. The movement we restored that improved her baseline measures is irrelevant in this context and the methodology of problem solving is for another time.
If we look at a case with pain being present – the story isn’t so different. Let me now ask you this; Is the leg length discrepancy/hip torsion the symptom or the cause of the pain? Let’s review some of what we know from the literature and general biomechanics.
- Firstly, the Sacroiliac Joint (SIJ) has roughly 2-4 degrees of nutation/counter-nutation. Hardly a major range of motion. Albeit – enough that may result in a functional leg length discrepancy.
- Secondly, the ligamentous structure of the SIJ is amazing. In conjunction with the force closure of the hips that occurs with gravity and ground reaction forces – we have an incredibly stable joint. The notion that this is commonly unstable is unfounded, and backed by weak literature. The literature suggests its prevalence with presenting back pain is between 10-65%, a grossly varying difference. What is interesting to note is that those studies that screened the spine first decreased their prevalence, and their SIJ pain provocation tests were found to be more sensitive. It is important to note that there is a relationship between the SIJ and lumbar spine, and movement through each will have a relative movement through the other (see here).
- Thirdly, if there has not been a traumatic mechanism of injury what makes us think that the hips would just “go out”? Oh because the left glute doesn’t work? Why doesn’t the glute work? It just decided to holiday in the Bahamas? No, there is an underlying reason – yes, likely due to lifestyle and movement behaviours, but the problem to be solved is not “let’s straighten the hips” the clinical reasoning would suggest we need to address the underlying problem – the functional meaningful problem to the client in front of us.
- A study (see here) found that 77% of asymptomatic subjects over the age of 30 had asymmetrical hips and 87% over the age of 40, evaluated by CT. Another study in 2015 (see here) found that 61% of their asymptomatic adult subjects had SIJ degeneration. So don’t treat the scan, and don’t jump to a conclusion. Correlation does not equal causation.
- Remember, scoliosis has a prevalence of over 10% in asymptomatic populations also (See here). The moral of the story, don’t treat the scan, treat the patient and problem solve.
What I am saying is that we need to stop putting our beliefs of patho-anatomical diagnosis onto our clients and address the actual problem. If we do this we won’t create further iatrogenic issues (see this paper here), and decrease the likelihood of a positive prognosis.
Now then, what is the actual problem?
Laslett et al (Link) looked at the validity of special tests for the SIJ. They found that by screening the spine using a McKenzie Mechanical Diagnosis and Therapy repeated movement protocol they increased the sensitivity of the 5 SIJ pain provocation tests used, from 78% to 87%. Showing a decrease in the false positives these tests can reproduce from other nociceptive structures. In addition to this, 3 of the 5 tests were required to be positive (post screening the lumbar spine) in order to rule in the diagnosis of the SIJ as the culprit [7, 8].
I can hear you thinking back to the golden question – if it is the back why is there a pelvic torsion? Or why is one glute being lazy? Why wouldn’t we just fix them, it’s worked for me in the past and I know how!?
Because you aren’t asking yourself the right question. You aren’t solving the problem. I invite you to give them a left glute activation exercise, as this may be, from your experience beneficial and therefore adds to your clinical reasoning. However, you need to assess if that alleviates the problem or has any positive or negative effect. If, although, it is the lumbar spine creating the issue you might find that there is some local left sided Quadratus Lumborum guarding, in turn increasing an anterior tilt of the left innominate, leading to increased activation of the left hip flexors, and an inhibition of the left gluteals. Voilà! You have a pelvic torsion (and potentially other somatic pain). No, I’m not saying this is the case, but it results in the same clinical presentation. So, before the therapist starts spouting theories to their clients, they need to take a deep breath and consider the actual question they need to answer. After all that is what the client is paying the therapist for.
In summary, this article isn’t so much about the prevalence of the SIJ being a dysfunctional joint, or about the relevance of scoliosis in back pain -- it’s about our communication with clients. It’s about solving the client's meaningful issue/problem, not creating new ones to show them how clever we are at evaluating their body. Be systematic, be mindful, ask the right question and then test, retest and solve. The evidence suggests that an effective screening of the lumbar spine before anything else is beneficial in determining a dysfunctional SIJ, but remember the low back and pelvis is filled with many nociceptive structures, you can’t rely on special tests for the answers, just your clinical reasoning. Good luck!
1. Simopoulos, T.T., et al., A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician, 2012. 15(3): p. E305-44.
2. Vleeming, A., et al., The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat, 2012. 221(6): p. 537-67.
3. Vogler, J.B., 3rd, et al., The normal sacroiliac joint: a CT study of asymptomatic patients. Radiology, 1984. 151(2): p. 433-7.
4. Eno, J.J., et al., The prevalence of sacroiliac joint degeneration in asymptomatic adults. J Bone Joint Surg Am, 2015. 97(11): p. 932-6.
5. Chen, J.B., et al., Prevalence of thoracic scoliosis in adults 25 to 64 years of age detected during routine chest radiographs. Eur Spine J, 2016. 25(10): p. 3082-3087.
6. Lin, I.B., et al., Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open, 2013. 3(4).
7. Laslett, M., Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther, 2008. 16(3): p. 142-52.
8. Laslett, M., et al., Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother, 2003. 49(2): p. 89-97.