Welcome to the next episode of the Redefining Physical Therapy podcast. I’m your host, Dr. Scott Gray. Happy Monday everyone. Today I would like to share a new episode with you, but more importantly, a patient case report and a case study. And so for those of you that are skeptics of the sacroiliac joint, being able to move into anteriorly or posteriorly, listen up. And so I was just like you believe it or not and I thought that the joint doesn’t really move that way and it doesn’t get out of place or anything like that. I’m going to deep dive into my case here and we’ll make you a believer.
I had a 66 year old female patient come into my office with a chief complaint of right side, lower back pain. Sitting made it worse, standing for prolonged periods made it worse. Walking made it worse. Transitions made it worse and laying on laying down at night. All red flags had been ruled out at this time. She had a history where she had been given a L4/5 and S1 facet joint block, no change. She’s even been given a hip bursa shot, no change. And she was even given a shot into the hip joint, no change. Upon examination, this is a patient that was stuck in. She had a right foot collapse, but but you can tell that it was a compensated foot because her other foot is in a uncompensated rear foot verus. Her iliac crests were normal. Her height and that sort of thing, hip rotation is good. Ankle joint mobility was good. But what she did have across all was weakness of the glutes, hamstrings and just kind of more of a global weakness of everything, but definitely didn’t have any hip extension strength, but had normal mobility.
She was positive for a SI joint cluster with a Froment Sign and with palpation for tenderness right over the sacral sulcus. And she had pain with extension of her spine. And that’s I think a good key point here is, earlier in my career, I would’ve said, “Facet, facet, facet,” but the symptoms don’t add up. She had pain with sitting and along those lines, even laying on her side. And so facet joint typically hurts worse in the morning when they first get out of bed and they’ll have pain across all those different movements of the spine that compressed that joint. But then they would be negative for the SI joint cluster in theory. And they would not have a palpation for tenderness over the sacro sulcus. And so that’s what this patient had.
But anyway, after several visits, we just started off with some basic things. I always typically work the hip, getting it stronger because the SIJ is typically is slave to the hip. The hip controls and rules. And so if that’s not corrected, then you’ll usually see this will manifest and manifest. And so this patient was getting better and better and I was actually getting ready to discharge her, but then she had a big flare up. And then since this time, for a couple of weeks there, it was pretty tough. She was very reactive so we had to use just more palliative stuff to calm down her reactivity, but I kept saying, “I’m missing something, I’m missing something.”
And so back to that foot that was kind of flat, especially when standing and walking, I thought, well, okay, does she have a leg length discrepancy?
Does she have limited dorsiflexion on that side that was causing that rear foot to go into eversion? That type of thing.
Or did she have some sort of injury to her spine that wasn’t talked about, that wasn’t allowing her to supinate?
And so I started looking back at things. And so I laid her down supine and I noticed she did have a leg length discrepancy.
And so I measured it from the umbilicus to the medial malleolus and we had a three-centimeter change indifference. And so I said, “Oh, that’s strange. I must’ve missed that.”
And just because her pelvis looked relatively neutral and that, but I really couldn’t figure out why that foot kept pronating and that’s really what was causing it.
Long story short, it looked like her right side, and then potentially when this happens actually, the right-sided SIJ could be anteriorly rotated or you could have a poster rotation on the left side.
You got to treat both.
That’s where I’m going with this. And so what confirmed my diagnosis, I had her sit up in a long seated position and her feet evened out. And so what I ended up doing was I did a posterior manipulation on the right and I did an anterior rotation on the left.
And then when she stood back up, she had basically no pain. She was able to walk, she was able to function and it was a game-changer for her.
That was I think a good case for people to note there’s very objective data.
We treated it, it got better. It changed with objective data afterward. It got better.
For all my SI joint people out there that think SIJ stuff doesn’t move. This is just a myth and your stuff doesn’t get out of place or move.
It does. And so it’s a very tough joint that to treat and I would say it’s probably one of the harder things to treat in the clinic, but you got to know what you’re looking for.
And I think my take-home point to you is don’t become biased and listening to some of these people out there, who these gurus that say, “The SIJ isn’t a problem and it doesn’t get displaced or it doesn’t move.”
It does move and it will play tricks on you and you’ll try all these other interventions and you’ll have shitty luck in outcomes with your clients and patients.
Get back to the basics and be sure to check everything and don’t miss what I had missed by putting the patient down in supine, measuring from the umbilicus down to the medial malleolus.
And then from there, discerning which one you need to posteriorly rotate and the ones you need to anteriorly rotate.