Question
I have a question about chiropractic technique. I have had 12 manipulations of SI joint (lying on side where pushes down hip, holding shoulder). Prior to this I was having mostly anterior thigh pain and groin pain. Recently I started having deep buttock muscle pain and sciatic type pain (a stabbing sensation in my groin) and most of symptoms are now in my butt and groin toward back of hip. I spoke with a couple of differnt professionals who warned me against this partuicular type of manipulation for SI stating that it could stretch ligaments and cause worse dysfunction and pain....basically it is the opposite of helpful!  I am very worried now.  In doing a manipulation, is he actually moving the joint and if so could it be in the wrong place now so to speak? What are yout thoughts on this side lying manipulation? Can it cause more hypermobility? It seems you would nto be taught something that can cause damage to ligaments. Please advise. I am so concerned that chiropractic care actually caused these symptosm and worse SI joint dysfunction. Id so, can it be reversed? What would you suggest for my symptoms? Thanks in advance!

Answer
Dear Jo,

Concerning your worries, I have a few points I would like to touch on. I want to clarify any misconceptions you have. First of all, sciatic type pain is pain that radiates commonly from the buttock, down the back of the leg and  below the knee.  It is not clear to me that you are actually having this type of pain from what you described.

All of the other symptoms you have described can come from sacroilliac 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.

It is not common to have sciatic pain in the groin due to the relationship of the anatomy and where the sciatic nerve distribution runs (down the back of the leg to the foot).  It is possible that you could have some overlap however of sacroillic pain as well as sciatic.

Moving on, as you probably already know, 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 indicated 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.

Concerning manipulation or adjustment of the joint, it is very common to use the side posture adjustment you have described to address SI 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 quicky and escapes the synovial capsule, just like when you open a champagne bottle quickly.

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.

Concerning your specific treatment, I sincerely doubt your chiropractor can generate enough force to actually move your joint out of aligment, the ligaments are too strong for that, but he may be creating more inflammation in the joint which will increase pain. For instance 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.

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.  He 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.  He 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 thing 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.

Because of the anatomy of the SI joint and the functional limitations of movement, I find it very difficult to believe that you have any hypermobility in the joint. 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), it is unlikely to have hypermobility in that joint unless you have had a forceful trauma such as auto injury.

In regards to other health professionals warning you about SI manipulation, until I have a good understanding of their expertise, I would not consider their point valid.  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.  I understand their point about a possible exacerbation of the ligamnetous complex of the SI joint, but this is just not a normal occurence.

I must conclude with this, after 12 visits you should have shown a consideral improvement from your initial date of treatment.  In our office you would have had a complete lumbar and pelvic physical examination, orthopedic testing, active ranges of motion would have been measured, neurological testing, reflexes and radiographic evaluation.  Treatment would have consisted of electrical stimulation, ice or heat depending on the acuteness of the problem, adjustments, functional stability and rehabilitation stretching and exercises either in office or at home depending on our exam findings.  I hope this was performed in your initial visit to the chiropractor you chose.  If not, you should look for a docotr who will be more thorough.

Jo, 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