“My Pelvis Is Out”
Let’s talk pelvic pain. This can be a controversial topic amongst clinicians. But I think we need to look at the evidence and consider that our thoughts and beliefs as to what causes pain has changed dramatically over the past 20 years.
It was once though that sacroiliac joint (SIJ) pain (the joint on either side at the back of your pelvis) was caused due to the pelvis being ‘out’ or ‘unstable’. We now know, through extensive research that this is unlikely to be the case. Our pelvis and its joints are in fact very strong and stable. Heck, if you are involved in a traumatic incident (such as a high-speed motor vehicle accident) you are more likely to fracture the bones of the pelvis before the ligaments around the SIJ or the Pubic Symphysis (PS) tear! So, unless you have been involved in quite a traumatic injury to the pelvis, it is unlikely that your pain is due to an instability of the pelvic joints.
The belief that our pelvis is ‘out-flared’, ‘in-flared’, ‘slipped up’, ‘slipped down’, and that this anatomical position is the cause of our pain was disproven about 22 years ago! Researchers took subjects (whom clinicians deemed their pelvis as being ‘out’), inserted some ball bearings into their pelvis (invasive!!) and x-rayed the position of their pelvis pre-treatment. The clinician then performed manipulation/mobilisation to the patient’s pelvis and with re-assessment deemed it to be ‘even’. That patient was then re-x-rayed to see if the pelvic position had in-fact changed. And guess what? The pelvic position was EXACTLY THE SAME as pre-treatment!
From research, we know that when we have pain in the SIJ it is not because there is too much movement in the joint. Rather, the area becomes sensitised (meaning it has become overly sensitive), therefore you feel it more.
Now that’s not to say that treatment with mobilisation or manipulation to the pelvis doesn’t work to reduced pelvic pain, however it is not due to the therapist changing the position of the pelvic joint. Instead, it may be working in other ways. Manual therapy is a very powerful modality to changing pain and muscle tone, but it is not actually changing the position of your pelvis! So, giving patients unhelpful beliefs that their pelvis is ‘unstable’, ‘fragile’, or ‘slipped out’ is just feeding into their fear about movement and hence reducing their function even further.
Furthermore, let’s not continually tell our patients that their pain is coming from the SIJ in their pelvis before we make sure they meet all the assessment criteria for diagnosis. There has been some good research looking into diagnostic criteria for SIJ pain termed ‘SIJ Pain Provocation Tests’. This is a cluster of 5 tests that the therapist will perform on the patient to ascertain if their pain is in fact coming from their SIJ. Three out of the 5 tests will need to be positive for the therapist to say that it is likely that their pain is coming from the SIJ. These tests in combination with the patient’s subjective history (nature of pain, area of symptoms etc) will give us a good indication if the pain is in fact SIJ caused, or perhaps coming from somewhere else but referring into the area of the SIJ joint. True SIJ pain in the ‘normal’ population (not pregnant women) is uncommon and is much more likely to be referred from the lumbar spine (low back)!
