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Sacro-iliac joint and beyond!

Discussion in 'Biomechanics, Sports and Foot orthoses' started by nicpod1, Oct 30, 2006.

  1. nicpod1

    nicpod1 Active Member

    Members do not see these Ads. Sign Up.
    Just a fishing expidition to see if anyone can help!

    I work with mainly Physios and this highlights my limitations regularly at the proximal end of things!

    During a biomechanical assessment I would routinely assess leg length difference and the folly of this without assessing the sacro-iliac joint / lumbar spine are becoming increasingly apparent.

    I have access to in-service training in this area, but would really like to be involved more extensively in this type of examination via an appropriate training course.

    Is anyone routinely assessing SIJ / lumbar spine? If so, can you recommend a good course?

  2. Ian Linane

    Ian Linane Well-Known Member

    Hi Nicloa

    You could try the Society of Sports Therapists. They have welcomed me on courses before but it may be that something so specific requires a more in depth course with them.

    BTW - I just thought I'd flag this up for interest.

    In a recent conversation about the Society insurance for treatments above the foot and ankle it was made plain that pods treating knees or hips (in this instance using peripheral mobilisations) would seem to be working outside the scope of practice for podiatrists and they may need to seek seperate insurance. If you are just assessing then it may not be relevant but you never know.

    So if you do train up in some of these other things it might be worthwhile checking this out for yourself.

    I worked alongside physios for five years, about 10 years ago. Great experience and left me wanting to go higher up the body in assessments and treatments. I now find it almost impossible to think of biomechanics of the foot seperate from looking at the rest.

  3. F. Fewster

    F. Fewster Member

    I am also interested in SIJ position and its effect on foot and leg function. Most of my knowledge has come from physios who specialise in pelvic alignment and muscle energy technique and I believe their associations periodically run courses on such. I understand Osteopaths also use these techniques. Routinely checking asis levels etc helps get a feel for it. I agree it is very important to look at SIJ position when you look at leg length, or your measurements are fairly irrelevant. A physio from this field should be able to help you (although in my experience there are limited physios who are really experienced with this) Sij position will also tend to have an effect on foot posture. I limit my involvement to trying to recognise if there is a SIJ rotation and if it is significant in terms of symptoms or biomechanical function, I'll get a pelvic physio involved, often prior to any script for a raise or orthotics. I'd like to see more Pod training in this field too. Craig Payne suggested a good book on the subject but I don't have the ref on me. Fleur
  4. nicpod1

    nicpod1 Active Member

    Thanks Ian and Fleur,

    I agree that ethically / scope of practice-wise it is better not to be 'treating' the SIJ or lumbar spine, but I would argue that we are treating it when addressing 'leg length' if we haven't actually assessed the SIJ and Lumbar spine before diagnosing leg length.

    I much prefer Physios to treat this area of course and I will have access to in-service training in this area from the Physios (one of whom is an SIJ 'expert'), but I would really like to be 'taught' formally how to assess it, which is why I was interested in a course in this area.

    If anyone has had ony good training, please will you let me know where?

  5. Atlas

    Atlas Well-Known Member

    I wouldn't discount osteopaths and chiropractors either. And like you have done, pick your practitioner.

  6. Donnchadhjh

    Donnchadhjh Active Member

    This very issue has recently raised its head in my workplace, thanks to our clinical lead in biomechanics. (Recently as in yesterday!)

    We are currently not assessing the SIJ and surrounding region as part of a biomechanical assessment (nor is it taught at undergraduate lvl at university), however due to refered pain and our podiatric intervention we are inadvertantley treating some SIJ conditions without establishing the actual cause of the pain - just the biomechanical symptoms.

    This has come to light because our clinical lead has spoken to many physio's and orthopaedic surgeons of their assessment and treatments.

    Needless to say this has opened a very big can of worms around the areas of "scope of practice" and of course "litigation"

    The UK may be behind the times... or not, however I too am very concerned about my work, and very interested (eager) to find out about additional training in Spinal and hip assessment.

    Just for the record our clinical lead is now composing guidelines and directions for our dept. in conjunction with Physio's, Orthopaedic surgeons, and NICE guidelines, despite the cloudiness in our "scope of practice" I feel it is a benificial thing - if nothing else it will improve our referals to Multi-disciplinary teams and hopefully save our necks if it ever ended up in the courtroom!

  7. Ian Linane

    Ian Linane Well-Known Member

    Hi all

    Even with the above in mind there arises the main issues of how do we actually determine, short of x-ray, leg length differences, what type they are and how much to intervene.

    At a sports therapy symposium on pain this year I was interested to hear a presentation by a lead biomechanics researcher at Lancashire university. (Dr. Jim -his last name evades me). Out of curiosity they studied the affect of unilateral raises on pelvic function in gait on a person with a 2cm LLD. The results have led them to take a more serious study into the subject. If I remember correctly what they found was that, in this instance, a 1cm heel raise restored the same level of pelvic function that a 2cm raise did.

    On scope of practice one of the issues I raised with the Society insurance was that Pods who might do musculoskeletal work will inevitably be drawn up to the knee and hip (at least in terms of peripheral mobilisations) as these techniques can be applied simply and in a way that may have positive affect upon a persons gait and possible foot function.

    Perhaps more people who are involved in musculoskeletal podiatry (whatever that means) should ask the Society to consider broadening its understanding of scope of practice in this context. Simply my opinion. Interestingly my current podiatric insurance cover already extends to this scope of practice.

  8. Donnchadhjh

    Donnchadhjh Active Member

    I wasn't there but I suspect it was Dr Jim Richards.

    I agree on the scope of practice bit, but if for example a person complaining of leg pain and for arguements sake we treated them for an LLD - the fact we havent established the cause of the pain (if it was SIJ in origin - just for arguements sake) wouldnt that mean we would be accountable for not performing a full assessment and establishing the ACTUAL cause as opposed to what we believed to be the cause of the problem before initiating the treatment???

    Edit: In the eyes of the law does it actually matter where our scope of practice ends - would they consider this when the fact is we treated something that may not have required treatment and may exaccerbate the problem.

    I have asked a couple of people about this - and off the cuff they do not know. As far as they can see we would be negligible but its outside our remit - so the question still stands - even though it is outside our written scope of practice - it still effects what we do - so to me that suggest a change in job description to extend to "Assessing the spine in the treatment of the lower limb." do you see what I mean or am I just blowing bubbles?

    (God! I hate law - its far too complicated)
  9. Craig Payne

    Craig Payne Moderator

    The Malalignment Syndrome: Biomechanical and Clinical Implications for Medicine and Sports - Wolfgang Schamberger
  10. conp

    conp Active Member

    Hi All,
    So pleasing to see the interest for the areas proximal to foot and ankle. :) It really makes sense to take these things into account. Cannot believe undergraduate pod courses (hopefully not the majority) do not educate students on these proximal influences.
    Very refreshing to read this and some other related threads.
  11. Donnchadhjh

    Donnchadhjh Active Member

    Thanks a lot Craig - I will be ordering this ASAP (after having a look around for it online of course :D)
  12. Ann PT

    Ann PT Active Member

    I admire anyone who wants to take on the sacroiliac joint and other proximal influences which may give a patient an apparent leg length difference. With oblique and transverse axes there are at least 10 different sacral deviations I can think of! Combine that with any rotation of the ilium and/or spinal scoliosis and leg length can be tough to figure out!

    One of the best courses for PTs in the states was taught by Jeffrey Ellis out of the Institute of Physical Arts in Steam Boat Springs, Colorado. Unfortunately Jeff passed away but his courses must still be available through the Institute. He made looking at the lumbar spine, sacrum, ilium, symphysis pubis, etc very methodical and easy to understand...not very easy to do without a great deal of practice but at least easy to understand. Good luck!

  13. Stanley

    Stanley Well-Known Member


    I took a course given by Jim Porterfield at Cleveland State University in 1983. It was a full quarter discussing just this information. I think he is still around in the Akron area. I incorporated this into an evaluation technique that was written up in:

    A preliminary study on asymmetrical forces at the foot to ground interphase
    J Am Podiatr Med Assoc 1985 75: 349-354.
    S Beekman, H Louis, JM Rosich, and N Coppola

    I still use this multistep evaluation as a preliminary examination. What I find from this, tells me the direction I need to go. For instance if I see an anterior innominate secondary to pronation, then I will look for a foot subluxation (usually a cuneiform) as a cause.


  14. DrGillman

    DrGillman Member

    'Just caught this thread... my question to those with interest in the SI joint is this: Is there really such a thing as SI joint malposition? The current paradigm (for chiro's at least) is that the "bone out of place" idea is outdated and unvalidated. Yet, patients continue to relay to me how other practitioners diagnosis and treat misaligned SI's. I don't think there is any evidence that it exists. Just like ankles, I believe it's a dynamic/functional joint system operating within the parameters of its architectural/anatomic limits.

    'My 2 cents on this...

  15. Stanley

    Stanley Well-Known Member


    Sometimes yes and sometimes no. Sometimes it is all foot related, and yes it moves back with the foot in neutral, and sometimes it doesn't because it is stuck, and manipulaton or muscle energy technique is indicated. That is why you have to do an evaluation.


  16. Shane Toohey

    Shane Toohey Active Member

    For the Australian Pods.
    I've spent the past few days in clinic with Dr Paul Conneely in Sydney.
    My eyes were popping out when I saw how quickly and easily he assessed and treated SIJ problems.
    One lady had had her problem since a fall in 1988. Obviously, widespread muscoloskeltal pain had spread since then and she had had every treatment under the sun.
    Firstly, he mobilised the feet, for an obvious improvement and then quite simply mobilised the SIJ area for a profound improvement.
    She was relatively pain free and functionally able to do things she had not been able to do for many years.
    I really don't think we can just look at ASIS or pelvic rims and say folk have LLL differences.

  17. neuromuscular

    neuromuscular Welcome New Poster

    It is of interest that the most difficult aspect of leg length is how to determine if the leg length difference is a valid "anatomical" leg length difference or if is a "functional" leg length difference. The classic patient supine and check the knee to knee and/or ankle to ankle is not very accurate in that when you check the ASIS to ASIS (R to L) there can substantial difference in the pelvic bone postitions. Since the head of the femur in the acetabulum is not in the exact center of the innominate bone, any rotation can create an artificial leg length difference. This is also true of the "measured" difference, because the innominate bone position is often not taken into consideration in the test.

    If you know that the innominate bone is in exactly the same position R to L, then the leg length test can be close.

    The best test for "anatomical" leg length difference is the radiology of the patient supine with the markings on the plate used to measure leg length difference.

    It is of interest that the SIJ test are inconclusive. The standard standing SIJ test with the landmarks of PSIS to sacrumn with hip flexion or torso flexion or the "gillett" test is opposite to the same test using the PSIS to sacrum with hip ABD. The "positive" in the standard SIJ test shows a moving of the PSIS away from the sacrum in the second test with hip ABD.

    To me it is more important to map the position of the innominate bones during hip ABD to determine if a true leg length is occurring or a functional. You can map the innominate bones by doing a four sided assessment of the PSIS to PSIS, ASIS to ASIS, and PSIS to ASIS (R&L) in a sequence using hip ABD from closed to 25 cm, 50 cm, 76 cm, 100 cm, etc to the ability of the patient to comply. This will tell you if they have a problem with innominate bone positioning. In those with no back pain, the landmarks will stay relatively close to each other in the transverse plane during hip ABD. In those with low back, SIJ or pelvic pain, the bones will move off the transverse plane as hip ABD progresses. In the majority with back pain that I have tested using this method the right innominate bone progresses in an anterior rotation while the left is inconsistent, but shows posterior rotation in approximately 60% of the patients and a neutral position in 20%.

    The quickest way to tell if the patient appears to have leg elngth difference is to check the innominate bone position in supine using the ASIS to ASIS. If the ASIS to ASIS is not equal in all planes, then it is most probable that the appearence of any difference in leg length is more likely to be a functional difference. If the ASIS to ASIS is equal in all planes, then the appearance of leg length difference could be a true anatomical leg length difference. This should be followed by radiographic examination using the proper plates.

    The SIJ is too often blamed when innominate bone position may be the greater factor. Our preoccupation with the SIJ testing has caused us to ignore the innominate bone positions.
  18. neuromuscular

    neuromuscular Welcome New Poster

    I agree! Try a four sided innominate bone position test using the landmarks of PSIS to PSIS, ASIS to ASIS, ANd ASIS to PSIS(R&L) with hip ABD on all four aspects. You will see that the innominate bones in those with pain move into anterior or posterior rotation.

    Best regards,

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