Question
QUESTION: I am writing because I have a few questions about the risks of an SI joint adjustment, using side posture manipulation.  I am an active male, who is physically fit.  I thought I pulled a muscle in my back this summer playing golf with some friends.  After about 6 weeks of physical therapy and not really improving, I went to the chiropractor for the first time.  My symptoms prior to the chiro were an ache on the lower left side of my back when sitting and standing for prolonged periods.  He adjusted my SI joint using side posture manipulation.  Later that evening, I experienced a light tingling sensation in my calf and foot.  I had a deep, dull ache in my joint and occasionally a stabbing sensation in the joint.  From that moment on, my pain went from a 3-4 to an 8 or 9, partly because I couldn't find a comfortable position (even lying hurt).  I had an MRI after the adjustment and found that my L5S1 disc is degenerated.  It has been approximately 3 months since my adjustment, and I am only about 10% improved.  

Here are my questions:
1. Can the chiropractor create a dysfunction in the SI joint?  If so, can it heal on its own or with physical therapy?
2.  What is the timeline for healing an SI joint?  Does it completely heal or will this be a chromic problem?
3.  What type of treatment plan is reasonable from a chiropractor?  I have thought about being evaluated by another chiropractor, but since I am so new to chiropractic, I really have no idea what seems reasonable.
4.  Finally,  is it possible the joint is dislocated or out of alignment?  Is that something I should be concerned about?

Thanks for your time in advance.


ANSWER: Dear Trevor,

Sorry to hear of all the issues and possible misconceptions concerning your SI and disk findings on MRI.  Hopefully I will be able to clear some things up.

Concerning your worries, I have a few points I would like to touch on. I want to clarify any misconceptions you have. Technically, ou cannot just push the SI joint back into or out of place, and it doesn't just pop out of joint either.  This is an anatomical impossibility without a severe and purposeful excision or rupture of the ligaments that surround and encompass the joint space.  That being said, you are correct in the notion that when the SI joint is working and moving properly that your pain should abate, your problem is likely more of a fixation of the joint m otion on one side (probably on the side without pain), and the opposite side is taking on to much motion to compensate creatuig inflammation and pain on that side.  

The low back and leg symptoms you have described can come from sacroiliac dysfunction, because the sacroiliac joint has pain patterns that encompass the entire leg depending on the dysfunction of the joint, the ligamentous complex and associated muscles. It gets its nerve supply from L3 to the S2 nerve roots.  There is also a type of pain called sclerotogenous pain which does not generate from the nerves, but rather from the ligament, cartilage and disk.  This pain is diffuse and covers broad areas....and can definitley be a factor due to the additional disc degeneration.

The majority of the stability of the SI joint comes from the ligaments.  They are probably the strongest in the body and a ligament serves to limit joint movement.  The actual movement that occurs within the SI joint is very small.  Most of the research I have read indicates that the SI joint moves only 1-3mm.  For many years it was thought that the joint did not move at all, but it is a true synovial joint and has movement, therefore it can be manipulated.

Concerning manipulation or adjustment of the joint, it is common to use a side posture adjustment to address the joint. Technically you are moving the joint with manipulation, but again we are talking about very slight movement.  The key to chiropractic manipulation is not the actual movement of the joint, rather the quick release of pressure within the synovial fluid of the joint...that is what makes the popping sound.  It is a release of gasses that happens quickly and escapes the synovial capsule, just like when you open a champagne bottle quickly. It is important for the chiropractor to differentiate between the sacrum and the ilium when adjusting this joint however...the hand placement is different for each respective anatomical location, and for function.  In my practice, I find that the sacrum is most often the problem and that is what needs to be adjusted rather than the ilium. Furthermore, the l5 vertebra usually rotates opposit to the problematic sacral side.  I would estimate that 90% of the time if I adjust the sacrum to the right, I will also adjust the L5 to ther left and vice versa.

When this happens joint receptors are firing signals to the brain.  These are called mechanoreceptors because they respond to movement and mechanical stimuli.  There are also proprioceptors which transmit information to the brain about body position and awareness.  Both of these transmitters send information to the spinal cord and brain which will inhibit the pain receptors in the joint which are called nociceptors.  It is a neurological and physiological relationship reducing inflammation and pain transmission.  That is why most patients feel pain relief, because the joint was working properly and the mechanoreceptors were being stimulated to reduce pain signals.  However, an adjustment can easily cuase and increase in localized pain the first few times it is utilized and this should have been explained to you by the chirorpactor before you left the office.  If he would have done that, it is likley that the follow-up visits would have suignificantly lowered your pain levels as the dysfunction was decreased.  A

Concerning your specific treatment, I would suggest that you do seek the care of another chiropractic physician for a second opinion.  You do not need to worry about creating excessive motion, the ligaments are too strong for that and all chiropractic techniques were designed and are taught in a manner not to take the joint into any pathological range of motions.  In other words an adjustment happens in the normal physiological range of motion of the joint....and it is unlikley that the chiropracto you saw injured the joint or created any instability...it's just too strong of a joint.

Now, if you are worried about side posture adjustments, there are other ways to adjust the SI joint however without as much of a stretch to your torso and the lower lumbar and pelvic musculature.  The doctor could use a drop table adjustment where you lay on your stomach, or your back.  He could also use an instrument to vibrate the joint space as well as some "PNF" stretching in the low back.  Again, hee could also elect to adjust the sacrum to the pelvis instead of the pelvis to the sacrum which would mean a different hand placement for the doctor on your body.  All of these things will accomplish the same task, but have different effects depending on the patient's general condition.  These are points you should discuss with your chiropractor.  In addition you should be using ice to help reduce the inflammation around the joint.

A reasonable treatment plan would be to see you 2x per week for 2-3 weeks to normalize the function of the joint and reduce your pain experience.  You may respond quicker...some patients are pain free in a week.  However, you should also learn proper stability exercises for the low back and pelvis to make sure the function is maintained, and the chiropractor should be able to teach you those exercises.

Because of the anatomy of the SI joint and the functional limitations of movement, it is the obvious choice for treatment. In my clinical experience as well as a thorough scientific review of the work of Dr. Andry Vleeming, (SI joint research on anatomy and biomechanics), I would expect significant pain reduction with treatment.

I have performed thousands of SI joint manipulations/adjustments on my patients and results from SI pain after manipulation has been over 90% effective.  These are some of the easiest cases to get better in my experience.  Although your case is chronic, you should expect to see decent results if the SI joint is the cause of the probelm.

Trevor, I hope this sheds some light on your concerns regarding treatment and ongoing symptomatology.  If you have any further questions or comments please feel free to respond back.  In addition to read any of Dr. Andry Vleemings research, you can look it up on Medline or Pubmed through the internet.  In addition, I would highly recommend a book written by Dr. Stuart McGill as a reference for low back dysfunction called LOW BACK DISORDERS, Evidence-based prevention and rehabilitation.  I am sure you can find it at your local college library.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoastehalthcare.net

---------- FOLLOW-UP ----------

QUESTION: Do you have any suggestions for finding a good chiropractor?  I was planning to print your response and bring it with me.  Thanks again for your time and thorough response.

Answer
Dear Trevor,

There is a section on my website that outlines a few ideas on how to find and work with a good chiropractor that was written for medical professionals.  It is on the front page under FOR MD'S/PT's ... feel free to read that.

However in the short term, you will need to check out a few local chiropractors websites and ask the doctor you choose for their credentials.  I have found through experience that Chiropractors who have been well trained with advanced post doctoral classes, certifications, etc... will welcome your challenge to them, and will be more than happy to provide you with written documentation on their credentials and ways to research them. Who doesn't want to talk about their achievements and accomplishments, right?

Ask logical questions about your condition and expect logical answers...if the doctor doesn't seem interested in answering your questions with a quick 10 minute free consultation, go somewhere else.  Any physician, medical, chiropractic or otherwise who resists questions from the patient is either hiding something, doesn't know the answer or just doesn't care.  Make sure you don't get that one!  And, feel free to print the response, a receptive doctor will be more than willing to briefly review it...I frequently do this with my patients.

Good Luck Trevor!

Respectfully,
Dr. Shawn Leatherman
www.suncoasthealthcare.net