Sick SI Syndrome: How We Taught Patients to Fear Their Pelvis

SI Pain Is Real. Pelvic “Malalignment” Is Another Story.

Another boring day in grad school.

The instructor seemed unusually excited about the sacroiliac joint.

He kept throwing around phrases I didn't fully understand—nutation, counternutation, upslip, downslip—but, apparently, an upslip was not to be confused with an anterior or posterior rotation.

He held his hands in front of him and twisted them around to demonstrate what the sacrum and pelvis were supposedly doing.

I'm still not entirely sure what he was demonstrating.

But everyone else in class seemed to understand—or at least they were doing a much better job of pretending to understand than I was—so I kept my mouth shut.

Fast-forward a few years.

I'm working in the clinic and a woman comes in with low-back pain. Except it isn't quite in the middle. It's more on one side.

Aha. SI joint.

Now, I had no idea how to treat an SI problem. Hell, I wasn't even confident I knew how to determine which one of the dozen classifications she supposedly belonged in.

So I went back to what we'd been taught.

I measured her legs.

I stared at her ASISs and PSISs.

I pushed around on her sacrum, mostly succeeding in causing her additional pain.

Then I called another therapist into the room because I wasn't quite sure what I was feeling.

He examined her and, surprisingly, decided the other side was higher.

Well, shit.

So we called in a third therapist.

He spent a few minutes palpating, pushing, looking at landmarks and moving her legs around. Then he walked out of the room and confidently announced that she had some combination of counternutation, an upslip and an innominate rotation.

Or something to that effect.

Wow, I thought.

That sounds kind of bad.

It was also weirdly impressive.

This therapist had just described the position of this woman's pelvis in greater mechanical detail than anything I had ever seen on an MRI report.

Using his thumbs.

At the time, I didn't think much more about it.

Years later, I would.

Because the more SI joints I evaluated, the more I started wondering whether we were actually detecting these incredibly specific positional faults—or whether we had created a language so complicated that nobody ever stopped to ask whether we could reliably measure any of it.

Welcome to Sick SI Syndrome.

Not sacroiliac joint pain.

Not inflammatory sacroiliitis.

Not pregnancy-related pelvic girdle pain.

Not traumatic pelvic-ring injury.

Those are legitimate clinical problems.

Sick SI Syndrome is something different.

It is the belief that small pelvic asymmetries represent meaningful mechanical dysfunctions that can be reliably detected with our hands, precisely classified, corrected with manual therapy, and then blamed again when the patient's symptoms return.

The problem isn't that the SI joint doesn't matter.

The problem is that we've built an extraordinarily detailed mechanical story around measurements we aren't particularly good at making.

Maybe it's time to move past it.

First: Yes, the SI Joint Can Hurt

Let's get this out of the way immediately.

The sacroiliac joint can absolutely be a source of pain.

Depending on the population and diagnostic criteria, SI-joint-mediated pain has been estimated to account for roughly 15–30% of chronic nonradicular low-back pain. Trauma, inflammatory disease, pregnancy-related changes and previous lumbar fusion may all be relevant in certain patients (Cohen et al., 2013).

So this isn't an article arguing:

“SI pain isn't real.”

That would just replace one oversimplification with another.

The better question is:

If the SI joint can hurt, does that mean we can identify tiny positional abnormalities of the pelvis and determine that those abnormalities caused the pain?

That's where things get much more interesting.

The SI Joint Moves—Just Not Very Much

Another mistake is saying:

“The SI joint doesn't move.”

It does.

It just doesn't move very much.

Sturesson and colleagues used roentgen stereophotogrammetric analysis to directly examine SI movement. Mean rotational movement between positions was approximately 2.5 degrees, while translation averaged around 0.7 mm. Perhaps even more interestingly, they found no difference in movement between symptomatic and asymptomatic SI joints (Sturesson et al., 1989).

A later systematic review of three-dimensional SI motion similarly concluded that SI movement consists of relatively small amounts of rotation and translation and questioned the clinical utility of attempting to identify these small motions manually (Goode et al., 2008).

Think about what we're claiming clinically.

We're placing our fingers over:

skin,

adipose tissue,

fascia,

muscle,

and considerable normal anatomical variation,

and then supposedly detecting minute motion occurring at a deep joint.

But we don't stop there.

We classify it.

Anterior innominate.

Posterior innominate.

Upslip.

Downslip.

Sacral torsion.

Nutation.

Counternutation.

Then we decide precisely which direction the bones need to move to correct it.

That is an extraordinary amount of information supposedly coming through two thumbs.

Your Thumbs Probably Aren't an X-Ray Machine

This is where Sick SI Syndrome starts falling apart.

A systematic review and meta-analysis by Ribeiro and colleagues examined palpatory SI mobility tests. Fifteen different tests were identified across 28 studies.

Reliability varied considerably.

More importantly, none of the included studies established concurrent validity of the palpatory mobility tests (Ribeiro et al., 2021).

That's important.

Reliability and validity aren't the same thing.

Two therapists agreeing that a PSIS moved differently doesn't mean the SI joint actually moved differently.

And even if you perform the test consistently and repeatedly get the same answer, that still doesn't prove you're measuring what you think you're measuring.

My early clinical experience probably illustrated this better than any statistics could.

Three therapists.

One patient.

Different conclusions.

And somehow the most complicated diagnosis sounded the most convincing.

We need to stop confusing:

“I can feel something.”

with:

“I know exactly what that something represents.”

The Manipulation Study That Should Have Changed This Conversation

One of my favorite SI studies was published in 1998.

Tullberg and colleagues recruited patients whose clinical examinations supposedly demonstrated unilateral SI dysfunction.

They performed SI manipulation.

After manipulation, the clinical positional tests normalized.

Perfect.

Patient has an abnormal SI test.

Manipulate the SI joint.

Test becomes normal.

Case closed.

Except the investigators also measured the actual relationship between the sacrum and ilium using roentgen stereophotogrammetry.

And the SI joint didn't change position.

Not in any of the ten patients.

The manipulation changed the clinical test.

It did not reposition the sacrum relative to the ilium (Tullberg et al., 1998).

That distinction is enormous.

Something changed.

Pain may have changed.

Muscle tone may have changed.

Guarding may have changed.

Movement strategy may have changed.

Sensory input may have changed.

Confidence may have changed.

But the evidence did not support the explanation:

“Your pelvis was out, and I put it back.”

This doesn't mean the manipulation was worthless.

That's another leap.

It means that if manipulation helped, the benefit probably wasn't because we physically put the pelvis back into alignment.

Stop Telling Patients Their Pelvis Is “Out”

This might be the most important part of the entire conversation.

Imagine being a patient with recurring low-back or buttock pain.

A healthcare professional examines you and says:

“Your pelvis is rotated again.”

You receive treatment.

You feel better.

Three weeks later, the pain returns.

What's the obvious conclusion?

My pelvis went out again.

So you return.

The therapist examines you.

Sure enough:

“Yep. You're rotated again.”

They correct it.

You feel better.

Congratulations.

We may have just manufactured a recurring mechanical problem in the patient's mind.

Now bending feels dangerous.

Running might knock it out.

Sleeping wrong might rotate it.

Lifting might shift it.

Crossing your legs might twist it.

Walking on uneven ground might move it.

The patient becomes increasingly vigilant about pelvic symmetry while becoming increasingly dependent on someone else to restore it.

That isn't resilience.

That's fragility with anatomical vocabulary.

But There Is One Group That Has Made Me More Cautious

There is one population that has repeatedly made me take pelvic-ring instability more seriously.

In my own clinical experience, the patients who have most made me wonder whether meaningful pelvic-ring mechanical changes might be contributing have overwhelmingly been women of childbearing age, frequently with a history of pregnancy and vaginal delivery.

That is a clinical observation.

It isn't proof.

But unlike the 55-year-old guy who supposedly rotated his innominate getting out of his pickup truck, pregnancy and childbirth provide an obvious biological reason to at least consider meaningful alterations in pelvic-ring mechanics.

Pregnancy is not a normal Tuesday at the SI joint.

The pelvis undergoes genuine physiological changes.

The pubic symphysis normally permits only small amounts of motion, but pregnancy produces changes in symphyseal width and mobility. Meanwhile, ligamentous properties, body mass, abdominal-wall mechanics, pelvic-floor demands, center of mass and gait all change during pregnancy (Becker et al., 2010; Vleeming et al., 2012).

And sometimes these changes aren't subtle.

True peripartum pubic symphysis diastasis exists.

A separation of approximately 1 cm or more is generally considered pathological and can cause substantial pain and difficulty walking. More significant pelvic-ring disruption can involve other structures as well, including the SI region (Anastasio et al., 2023).

That's not somebody deciding one PSIS looks a little higher.

That's a measurable pelvic-ring problem.

So no, I don't think pelvic instability is imaginary.

In fact, the existence of real pelvic instability is part of the reason I think we should stop diagnosing it so casually.

Don't Blame Everything on Relaxin

Pregnancy also gave us another wonderfully simple rehabilitation story.

Pregnancy increases relaxin.

Relaxin affects connective tissue.

Therefore:

Relaxin → loose ligaments → unstable SI joint → pelvic pain.

It's a nice story.

Unfortunately, biology rarely cooperates with nice stories.

A systematic review examining serum relaxin and pregnancy-related pelvic girdle pain found the evidence inconsistent. Most of the higher-quality studies did not demonstrate a clear association between circulating relaxin concentrations and pelvic girdle pain (Aldabe et al., 2012).

That doesn't mean hormones are irrelevant.

Of course pregnancy alters the hormonal environment.

It means saying:

“Her relaxin made her SI unstable.”

is considerably more certainty than the evidence allows.

And there's an even bigger issue.

Laxity isn't pain.

Two women can undergo similar pregnancy-related physiological changes and have very different experiences.

One develops severe pelvic girdle pain.

The other continues exercising without meaningful symptoms.

Once again:

Structure matters.

But structure doesn't tell us the entire story.

What About Vaginal Delivery?

This one deserves some restraint too.

From a mechanical perspective, it's understandable why vaginal delivery caught my attention clinically.

Childbirth can place enormous demands on the pelvic ring, and rare but legitimate injuries such as pubic symphysis diastasis can occur during delivery (Anastasio et al., 2023).

But we shouldn't make the opposite mistake and conclude:

Vaginal delivery = permanently unstable SI joints.

Studies examining persistent postpartum pelvic girdle pain paint a much more complicated picture.

A systematic review and meta-analysis by Wiezer and colleagues identified factors such as previous low-back pain, pelvic girdle pain during pregnancy, higher prepregnancy BMI, depression during pregnancy and heavy workload during pregnancy as potential risk factors for persistent postpartum symptoms. Obstetric and infant-related factors were not consistently predictive (Wiezer et al., 2020).

Another systematic review similarly found that symptom severity, previous low-back pain, multiple painful pelvic locations and other factors may be associated with persistent symptoms, but the overall certainty of evidence was low to very low (Wuytack et al., 2018).

So my observation remains exactly that:

an observation worth investigating, not a diagnostic rule.

I've seen enough women with persistent posterior pelvic complaints following pregnancy and vaginal delivery that it gets my attention.

It does not give me permission to manufacture certainty.

And frankly, that is the point of this entire article.

Maybe “Instability” Isn't Even the Best Word

Perhaps we're framing some of these patients incorrectly from the beginning.

Instead of imagining the SI joint sliding around excessively, it may be more useful to think about load transfer across the pelvic ring.

The pelvis sits between two moving lower extremities and a moving trunk.

During walking, running, lifting, carrying and single-leg activity, forces have to move through that system.

SI stability depends on much more than the position of one bone relative to another.

Bony geometry matters.

Ligaments matter.

Joint compression matters.

Muscles matter.

Fascial connections matter.

Ground-reaction forces matter.

This broader idea has been described using concepts such as form closure and force closure (Vleeming et al., 2012; Vleeming & Schuenke, 2019).

Pregnancy and childbirth can alter virtually every contributor to that system.

Abdominal-wall function changes.

Pelvic-floor demands change.

Hip and trunk demands change.

Walking changes.

Single-leg loading changes.

Body mass changes.

Activity changes.

Sleep and recovery certainly change.

A woman can therefore have a very real postpartum pelvic problem without requiring us to believe her sacrum is repeatedly popping out of position.

That's a much richer model.

The SI Belt Is Actually Pretty Interesting

This is one place where the test → intervene → retest approach becomes far more useful than staring at pelvic landmarks.

Take someone with pregnancy-related or postpartum pelvic girdle pain.

Find a meaningful comparable sign.

Walking.

Stairs.

Rolling in bed.

Single-leg stance.

Active straight-leg raise.

Then apply external pelvic compression or an SI belt.

Retest.

If the task becomes noticeably easier or less painful, that's useful information.

It does not prove:

“Her right innominate was anteriorly rotated.”

It tells us:

Changing external compression and load transfer through the pelvic ring changed her symptoms.

That's something we can work with.

European guidelines for pelvic girdle pain have supported functional tests such as the active straight-leg raise while recommending against SI mobility palpation tests (Vleeming et al., 2008).

Fitzgerald and colleagues also found that applying an SI belt to pregnant women with posterior pelvic girdle pain immediately reduced difficulty with the active straight-leg raise. Participants demonstrated improvements in pain and function during a four-week period of belt use, although the immediate response did not predict longer-term outcomes (Fitzgerald et al., 2022).

That makes far more sense to me clinically.

Find a task.

Change a variable.

Retest.

Provocation Tests Are Different From Positional Tests

This distinction matters.

Tests such as thigh thrust, compression, distraction, sacral thrust and Gaenslen's aren't trying to determine whether an innominate is rotated three millimeters.

They're trying to reproduce familiar symptoms by loading the region.

That's a much more modest claim.

But even these tests shouldn't be treated as magic.

A 2021 systematic review and meta-analysis found that clusters of SI pain-provocation tests were not particularly strong for ruling in SI-mediated pain.

Assuming a prevalence of approximately 20%, a positive cluster produced an estimated post-test probability of only around 35%.

A negative cluster performed better.

The estimated probability of SI-mediated pain following a negative cluster fell to approximately 8%, although the certainty of evidence was rated very low (Saueressig et al., 2021).

So instead of:

“Three SI tests are positive. Your SI is the problem.”

A more defensible interpretation is:

“Several different ways of loading this region reproduce your familiar symptoms, so the SI region may be contributing.”

That is less dramatic.

It's also much harder to misuse.

Pain Location Is Not a Mechanical Diagnosis

Posterior pelvic pain is messy.

The lumbar spine can refer pain into the area.

The hip can refer pain posteriorly.

Muscle and connective tissue can contribute.

Neurological structures can contribute.

The SI joint can contribute.

Sometimes several things contribute at once.

There is no single historical feature or routine physical examination test that reliably identifies the SI joint as the pain generator in every patient.

Controlled image-guided anesthetic blocks have therefore frequently been used as a reference standard in research on SI-mediated pain, although even diagnostic injections have limitations (Cohen et al., 2013).

That should make us humble.

If clinicians performing image-guided injections still deal with uncertainty about whether the SI joint is generating pain, perhaps we shouldn't be overwhelmingly confident because one PSIS looks a little higher.

What About Leg-Length Tests?

This is another place where the mechanical SI narrative becomes seductive.

The patient lies supine.

Compare the malleoli.

Then they sit up.

One leg appears to change length.

Boom.

Anterior innominate.

Or posterior innominate.

Except the apparent position of the feet can change for all sorts of reasons unrelated to meaningful SI displacement.

Hip rotation changes.

Knee position changes.

Foot position changes.

The patient shifts.

The examiner changes pressure.

The pelvis rotates globally on the table.

Normal anatomical asymmetry exists.

The observation itself isn't necessarily imaginary.

The interpretation is the problem.

A change in apparent leg length does not automatically mean we've identified the direction of a sacroiliac positional fault.

But True Leg-Length Discrepancy Is Real

And this is where I don't want to swing the pendulum too far in the opposite direction.

Actual leg-length discrepancy exists.

Not:

“Your leg looks shorter because your innominate rotated backward.”

I mean one lower extremity can actually be structurally shorter than the other.

The femur can be shorter.

The tibia can be shorter.

Previous fracture, surgery, developmental differences and joint reconstruction can create real differences in limb length.

That's not an SI theory.

That's anatomy.

And unlike trying to determine sacral torsion through our fingertips, we have reasonable ways of assessing it.

A 2021 systematic review examining clinical and imaging methods for leg-length discrepancy concluded that the block test appears to be the most useful clinical assessment, while full-length standing AP radiography appears to be the most valid and reliable method for quantifying anatomical leg-length discrepancy (Alfuth et al., 2021).

That is a very different thing from laying someone supine, looking at their shoes and announcing that their pelvis rotated.

And this distinction has mattered quite a bit in my own practice.

I've “fixed” more than a few long-term Sick SI patients with something remarkably unexciting:

a heel lift.

These were sometimes patients who had spent months—or years—being told their SI joint kept rotating, slipping, getting stuck or going “out.”

They'd been manipulated.

Corrected.

Muscle-energied.

Realigned.

Given exercises to “hold the correction.”

Then they'd come back because, apparently, their pelvis had escaped again.

Some had even been treated by therapists who considered the SI joint a particular area of expertise.

Then I'd look at them standing.

One iliac crest remained consistently lower.

Put blocks under the short side.

Pelvis levels out.

Their painful standing, walking or single-leg task improves.

Hmm.

Put a small lift in the shoe and see what happens.

Sometimes the answer was dramatic.

Weeks or months of elaborate SI treatment, and a boring little piece of material under the heel made the problem substantially better.

I'll admit that a few of the “SI specialists” involved in those cases weren't particularly enthusiastic about that explanation.

I can understand why.

“This leg is actually shorter” isn't nearly as exciting as a left-on-left sacral torsion with an anterior innominate and an upslip.

And a heel lift doesn't require someone to put your pelvis back into place every Tuesday.

But there is some research supporting what I've seen clinically.

A randomized controlled trial by Defrin and colleagues studied people with chronic low-back pain and leg-length discrepancies of 10 mm or less. Correcting the discrepancy with individually fitted shoe inserts significantly reduced both pain and disability compared with the control group (Defrin et al., 2005).

Golightly and colleagues later reported improvements in pain and disability after shoe-lift intervention in patients with chronic low-back pain and measured limb-length inequality, although their study was small and did not include a control group (Golightly et al., 2007).

A systematic review by Campbell and colleagues found low-quality evidence that shoe lifts can reduce pain and improve function in adults with leg-length discrepancy and painful musculoskeletal conditions. Importantly, the authors also concluded that we still don't have good evidence establishing exactly how large a discrepancy must be before it matters, or exactly how much of that discrepancy should be corrected (Campbell et al., 2018).

That caveat matters.

I'm not arguing:

“Everyone with a five-millimeter leg-length discrepancy needs a heel lift.”

Small discrepancies are common.

Many people compensate for them perfectly well.

Not every asymmetry causes pain.

And simply finding a structural leg-length difference doesn't prove that it caused the patient's symptoms.

But that's exactly why the retest matters.

If I suspect a meaningful leg-length discrepancy, I can put a block or temporary lift under the shorter side and immediately repeat the meaningful task.

Standing.

Walking.

Single-leg stance.

Squatting.

Whatever reliably reproduces the complaint.

If nothing changes?

Maybe it isn't particularly important.

If the patient's familiar symptoms change substantially?

Now I'm interested.

Once again:

Find a variable. Change it. Retest.

And here's the irony.

For years we've been willing to believe that someone's leg appears short because of an invisible pelvic rotation we think we can feel with our thumbs.

Yet sometimes an actual measurable leg-length discrepancy gets ignored because we've already decided the pelvis is the problem.

That's backwards.

A true leg-length discrepancy doesn't validate Sick SI Syndrome.

If anything, it demonstrates why we need to get better at distinguishing measurable structural differences from stories we create around positional tests.

Stop Treating Asymmetry Like Pathology

Humans aren't symmetrical.

Look at enough people and you'll find:

Different shoulder heights.

Different iliac crest heights.

Different PSIS heights.

Different hip rotations.

Different foot positions.

Different muscle bulk.

Different limb lengths.

Different spinal curves.

And somehow many of these horribly asymmetrical people walk around completely pain-free.

Structural variation isn't automatically dysfunction.

And asymmetry isn't automatically a treatment target.

If changing an asymmetry meaningfully changes someone's function, investigate it.

But don't assume every asymmetry requires correction simply because you found it.

Otherwise the examination becomes a scavenger hunt for imperfections.

And if you look hard enough, you will always win.

Your Pelvis Is Not That Fragile

Consider what the pelvis actually does.

You walk.

Run.

Climb stairs.

Jump.

Land.

Carry groceries.

Lift children.

Deadlift.

Rotate.

Stand on one leg.

Trip.

Recover.

Pregnancy places dramatically different demands on the entire system.

Childbirth can place extraordinary demands on it.

The SI joint participates in transferring substantial forces between the trunk and lower extremities and is supported by an extensive ligamentous, muscular and fascial system (Vleeming et al., 2012).

This isn't a stack of Jenga blocks waiting for one wrong movement to knock an innominate out of place.

Can the region become painful?

Absolutely.

Can tissues become sensitized?

Of course.

Can someone temporarily lose tolerance to particular loading patterns?

Yes.

Can genuine pelvic instability occur?

Yes.

Can a true leg-length discrepancy alter how someone loads the pelvis?

Absolutely.

But those are very different statements from:

“You slept wrong and your pelvis slipped out.”

The Real Question: What Changes the Patient?

Instead of asking:

“Which way is the sacrum rotated?”

Try asking:

“What reliably changes this patient's symptoms?”

Now the examination gets much more interesting.

Maybe repeated lumbar movement changes the symptoms.

Maybe hip rotation changes them.

Maybe changing stride length changes them.

Maybe loading the glute changes them.

Maybe trunk position changes them.

Maybe external pelvic compression changes them.

Maybe a heel lift changes them.

Maybe thoracic rotation changes them.

Maybe arm swing changes them.

Maybe adding resistance helps.

Maybe taking resistance away helps.

Now we're learning something useful.

Not necessarily what microscopic structure is “wrong.”

But how the patient's system responds to load.

And Yes—Look Above the Pelvis

The pelvis does not function in isolation.

The latissimus dorsi connects into the thoracolumbar fascial system.

The contralateral gluteus maximus participates in cross-body force transfer.

The thorax rotates.

The arms swing.

The hips rotate.

Ground-reaction forces travel upward.

Forces from the trunk travel downward.

Human gait is an alternating cross-body activity.

The SI region has been described as part of a much broader muscular, fascial and ligamentous load-transfer system rather than an isolated articulation (Vleeming et al., 2012).

So if changing shoulder position, thoracic rotation, arm swing or lat recruitment changes someone's familiar posterior pelvic pain, that deserves attention.

It doesn't prove:

“Your lat caused your SI dysfunction.”

Let's not replace one rigid story with another.

But it does tell us something important:

Symptoms around the posterior pelvis can be influenced by regions well beyond the SI joint.

That's a much richer clinical model than endlessly correcting an innominate.

Manual Therapy Isn't the Enemy

None of this means SI manipulation is useless.

That's another false binary.

A manipulation might decrease pain.

It might improve movement.

It might decrease guarding.

It might make a painful task easier.

It might give someone enough relief to exercise.

It might simply feel good.

Those are legitimate clinical outcomes.

What needs to change is the explanation.

Instead of:

“Your SI was out and I put it back.”

Try:

“That technique changed your symptoms. Let's use that window to get you moving and see what you can do now.”

One explanation creates dependency.

The other creates opportunity.

Exercise Doesn't Need to “Hold the Correction”

The same problem appears with exercise.

After supposedly correcting the pelvis, patients are frequently given stabilization exercises to:

“Keep the SI in place.”

Again, think about what that language teaches.

Your body cannot maintain its own alignment.

Your muscles need to hold your skeleton together.

If you stop performing these special exercises, your pelvis might slip back out.

I don't think we need that story.

Exercise can simply do what exercise does remarkably well:

Build capacity.

Increase strength.

Improve tolerance to load.

Expose someone gradually to previously painful movements.

Increase confidence.

Expand movement options.

A systematic review of motor-control exercise for pelvic girdle pain found that isolated motor-control exercise was not clearly superior for short-term pain, while multimodal approaches incorporating exercise performed better in some of the included trials (Mapinduzi et al., 2022).

We can prescribe good exercise without pretending those muscles are physically holding a corrected innominate in place.

A Better SI Examination

Maybe the SI examination of the future looks less like this:

Palpate → classify → correct → recheck alignment

and more like:

Listen → reproduce → modify → retest → progressively load

Start with the patient's actual complaint.

What hurts?

When?

During what task?

At what load?

How long does it take to appear?

What makes it better?

What makes it worse?

Can you reproduce it?

Then start changing variables.

Lumbar position.

Hip position.

Trunk position.

Stride.

Arm swing.

Load.

Speed.

Range.

External support.

Leg-length correction when appropriate.

Muscle recruitment.

Find something that changes the patient's meaningful comparable sign.

Then use that information to build treatment.

That's an examination based on response rather than mythology.

Don't Throw Out the SI Joint

There are patients in whom the SI joint deserves serious consideration.

Inflammatory sacroiliitis is real.

Pregnancy-related pelvic girdle pain is real.

Pubic symphysis diastasis is real.

High-energy pelvic trauma is real.

Post-fusion SI-mediated pain is real.

Degenerative SI pathology exists.

True structural leg-length discrepancy exists.

Some carefully selected patients with persistent SI-mediated pain may ultimately require injections, radiofrequency procedures or surgical evaluation.

This isn't an argument for ignoring the SI joint.

It's an argument for respecting it enough to stop pretending our thumbs possess diagnostic abilities the evidence hasn't demonstrated.

Maybe Nothing Was Ever “Out”

This is the part patients often need to hear.

If you've been told for years that your pelvis keeps rotating, slipping, twisting or going out of alignment, consider another possibility.

Maybe your pelvis wasn't repeatedly falling apart.

Maybe you had pain.

Maybe certain loads irritated it.

Maybe your nervous system became protective.

Maybe movement became guarded.

Maybe strength and capacity decreased.

Maybe pregnancy or childbirth changed the mechanical demands on your pelvic ring.

Maybe one leg really was a little shorter than the other.

Maybe treatment temporarily changed your symptoms.

And then somebody created a structural explanation for why you felt better.

The relief may have been real.

The explanation didn't have to be.

SI Pain Is Real. Sick SI Syndrome Doesn't Need to Be.

The sacroiliac joint deserves neither dismissal nor mythology.

It is a real joint.

It moves.

It transfers load.

It can hurt.

Pregnancy and childbirth can genuinely alter the mechanical environment of the pelvic ring.

True pelvic instability can occur.

True leg-length discrepancies exist and, in selected patients, correcting one may meaningfully change symptoms.

But none of that proves that we can reliably identify tiny rotations of the innominate with our fingertips.

It doesn't mean an asymmetrical PSIS is pathological.

It doesn't mean a leg that appears longer during a table test has been pulled downward by a pelvic rotation.

And it certainly doesn't mean a patient needs someone to repeatedly put their pelvis back into place.

Perhaps the most useful question isn't:

“Is your SI joint out?”

It's:

“What can you currently not tolerate—and what changes it?”

Then:

“How do we build that capacity back?”

That's a less impressive story.

There are fewer magic corrections.

Fewer anatomical diagnoses based on millimeters.

Fewer opportunities for the clinician to be the person who fixes the patient.

But it gives the patient something much more valuable:

A pelvis they can trust.

-the semi-pissed off PT- share, comment, heal the world

References

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Alfuth M, Fichter P, Knicker A. Leg length discrepancy: a systematic review on the validity and reliability of clinical assessments and imaging diagnostics used in clinical practice. PLoS One. 2021;16(12). doi:10.1371/journal.pone.0261457.

Anastasio MK, Anastasio AT, Kuller JA. Peripartum pubic symphysis diastasis. Obstetrics and Gynecology Survey. 2023;78(6):369–375. doi:10.1097/OGX.0000000000001156.

Becker I, Woodley SJ, Stringer MD. The adult human pubic symphysis: a systematic review. Journal of Anatomy. 2010;217(5):475–487. doi:10.1111/j.1469-7580.2010.01300.x.

Campbell TM, Ghaedi BB, Tanjong Ghogomu E, Welch V. Shoe lifts for leg length discrepancy in adults with common painful musculoskeletal conditions: a systematic review of the literature. Archives of Physical Medicine and Rehabilitation. 2018;99(5):981–993.e2. doi:10.1016/j.apmr.2017.10.027.

Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert Review of Neurotherapeutics. 2013;13(1):99–116. doi:10.1586/ern.12.148.

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