The Mysterious, Misunderstood, and Mistreated SI Joint
In this episode, Anna shares her core beliefs about the SI joint:
1. The SI joint moves, and the movement is what makes us uniquely human
2. The SI joint, in general, is misunderstood and, therefore, often mistreated
3. The SI joint is connected to and influenced by everything- the viscera, the central nervous system, the deep fascia, the myofascial /musculoskeletal system, and the peripheral nerves
Throughout the episode, Anna talks about the relevant anatomy that is connected to and influences the mobility of the SI joint, how it relates to common pain referral patterns, understanding SI joint pain driven by hypermobility, and how the mobility of the SI joint can actually be a foundational assessment not just for the joint itself but for the full body, examining how the influence of the viscera and nervous system affect whole body movement and mobility.
Check out this YouTube video on SI mobility
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[00:00:00] Hello. Hello, hello. So here we are, another episode of the Unreal Results Podcast. Welcome back. Thank you for being here. Uh, it's, it's been, um, it's been really surreal to have a podcast. , I'm really enjoying it and I hope you are too. and it's just so cool to see all the downloads and see people talking about it and messaging [00:01:00] me and I really appreciate that.
[00:01:02] Today we're gonna talk about the SI joint, so that SI joint's something I'm really passionate about talking about. It's a really misunderstood joint, I believe, and also just tends to be. Well, it's misunderstood, mistreated a lot and, um, yet always talked about, right? Like I feel like it's really common for people to throw around the idea of somebody having an SI joint dysfunction or SI joint, um, pain provocation.
[00:01:42] and then treating it in a similar way regardless of what's going on. So we're gonna dive into a lot of things Si joint, it's often on my mind because it's, uh, a primary assessment test that I use. Um, but it's [00:02:00] especially on my, my now as I have opened the doors for the results cheat code and, um, Which leads into the LTAP Level one course and I'm teaching an LTAP level one course in person this weekend in Miami.
[00:02:15] And so just all of the tests, the LTAP stands for the Locator Test Assessment Protocol. All of the tests have been in my mind as I am talking about the content and organizing my thoughts around teaching it. So the Results cheat code is a six day. Course live online course, and it's basically is the first test of the LTAP
[00:02:44] and this test, why? It's the first test, it's the sequence of five tests the whole LTAP.. But this first test, why I call it the Results Cheat code, is because this is the test that gives us the most information. And [00:03:00] if it's the only test you ever do, it's gonna help get you great results because it's going to direct you exactly where the body wants to start, meaning where the body is protecting.
[00:03:16] And that protection pattern is what often limits people's mobility, increases pain and decreases function . So this is different than finding the pain generator or finding the, , biomechanical driver of a pain generator. This is one layer deeper.
[00:03:39] This is looking at what is driving a issue in the body that may lead to a biomechanical. issue and then which may lead to tissue pathology. Right. So it's like, you remember [00:04:00] that song as a kid, you're like singing it and it's like, you know. In the woods, there was this tree, and on this tree there was this branch.
[00:04:08] And on this branch there was this nest. And the nest there was a bird. And then like you work your way back and the bird and the nest. And the nest on the branch and the branch and the tree, and the tree in the wood and the green grass grows all around. All around and the green grass grows all around.
[00:04:22] This is exactly what we're doing. We're taking a step back, you know, in the industry. If we look at the sort of the lifespan of the industry of um, Physical therapy of athletic training. It's a patient comes to you with knee pain. Really old school was your knee hurts? Let's look at the knee. Only at the knee and treat the knee and it was successful.
[00:04:47] Sometimes you put your hand on somebody, people get better. The body is amazing. The body will get better eventually, often. And then as we learned more about movement as we learned more, [00:05:00] Pathology, we realized, hmm, there's some biomechanical things going on at other joints that could be creating some of this pain at this joint, you know, at the knee.
[00:05:12] And so then we started to see every knee as a hip problem or a core problem. Right? And so now we're taking this even a step further of perhaps. biomechanical issues that we see at the foot or at the hip is coming from a deeper layer of this protection pattern because the body is. Protecting something that's more important, which is the visceral organs and the central nervous system.
[00:05:46] So if you haven't already listened to the episode where I discuss MovementREV philosophies and methodology, this is a good time to pause this episode and go back to that episode and I'll link it in the show notes [00:06:00] because it is so important to understand like this lens of you we're looking at in the body is realizing that,
[00:06:06] even though we operate in an industry that biases, places, value on movement places, everything on the musculoskeletal system, everything on the biomechanics, that is just not how the human organism operates. So this is what's great about the results, cheat code course is this is deeper level at figuring out the driver
[00:06:34] and appreciating how the viscera and the nervous system can influence full body function and therefore pain and injury and pathology, those kind of things. So, Like I said, the results, cheat code is the first test. of the LTAP, that First test is an SI joint mobility test, and the SI joint is the perfect joint for this [00:07:00] because it is literally connected to everything.
[00:07:04] And we're gonna go over a lot of those pieces of, of anatomy today on this podcast, and I'm gonna try my best to keep it as organized as possible. But there's so many ideas bouncing around in my. head.
[00:07:17] So the SI joint is directly connected and influenced by the visceral organs, the central nervous system, the peripheral organs, and the fascial system, both from a musculoskeletal or like, um, anatomy trains type myofascial system, as well as deeper fascia that connects all of the containers of our trunk and head.
[00:07:42] And, um, we're gonna also, you know, what makes the, um, si joint a perfect joint to assess full body function, um, have this full body assessment and ask the body the first of three [00:08:00] questions. So the first qu question being, are you protecting something important, the viscera or the central nervous system or not?
[00:08:10] The cool thing about it is because the joint doesn't move a lot, but it does indeed move. It should move. , it really allows for a great assessment test because there's not a whole lot of room for interpretation. It's not like your shoulder joint that has like 180 degrees of range of motion. And so you know what is. . You know, if I were to ask you what somebody's shoulder range of motion is, or even like if you consider their shoulder mobile or not, or if there is a change with a breath hold, it's like sometimes when there's so many degrees of motion, it's sort of splitting hairs to see if there is a change.
[00:08:56] The SI joint is great because it is either [00:09:00] moving or it's not moving. . You know, you could argue that maybe you could feel when it moves too much, but you know when the movement is supposed to be millimeters of movement, it's either like you feel it or you don't feel it. It's moving or it's not moving.
[00:09:19] Now, when it comes to the SI joint, and SI joint dysfunction. So if you look in the research, SI joint dysfunction is actually the name given when someone has SI joint pain. So that is, I think sometimes what makes things not so clear is because it's confusing is SI joint dysfunction. A joint that doesn't move, or a joint that moves too much or just a joint, that's painful.
[00:09:54] Right. So that's important to talk about. Um, [00:10:00] and understanding too what this assessment is, what the SI joint assessment is that I use is more of a mobility test. Than a pain provocation test. Now, that doesn't mean I don't care about SI joint pain because of course I care about SI joint pain, but whether someone's pain is in their SI joint or in their shoulder or in their knee or in their ankle, I really want to first go as deep as possible to know is a protective pattern of the visceral organs or the central nervous.
[00:10:39] Part of the driving factors to this pain. So I still want to know that if for someone's SI joint pain, it very well may be that someone's SI joint pain is being driven by a visceral protective pattern [00:11:00] or by an issue in their lower. . And so this is where, you know, this conversation on the podcast might be like a little, um, disorganized because we need to talk about both because I don't want this podcast to just be about the results cheat code.
[00:11:19] I want you interested in the results cheat code to sign up for the course. It's free, but I also want to not make this whole talk about SI joint pain only. So we're gonna talk about that first. So, si joint pain in my experience, is usually on the side of the joint that moves too much, not the side that doesn't move.
[00:11:52] And this. tends to track in the patient situations I've [00:12:00] seen and the, literature. So hypermobility, true si joint hypermobility. So a joint that moves too much tends to be only seen in women that are pregnant or postpartum. Got injured while pregnant or postpartum due to the hormonal ligament laxity.
[00:12:26] Inherently that happens, especially around the pelvis, right? To get the baby out there was more motion and they may have had some sort of mechanism of injury. or perhaps just the laxity itself and everyday life was the mechanism of injury. Oftentimes though, in those women, unless they had a like more specific occult injury during that time, once their hormones go [00:13:00] back, you know, under control gets back under control and regulated, um, the stiffness is restored to those ligaments and.
[00:13:10] Oftentimes pain will go away again as long as there wasn't an additional, um, actual injury to that area during that time of ligamentous laxity. The other typically reported si joint pain and injury scenarios are high velocity forces such as a motor vehicle accident. or some sort of trauma in sport that occurred with an asymmetrical position of the hips.
[00:13:48] So one si joint was wound up in posterior rotation, and then the other one was round wound up in anterior rotation, and then either load, uh, excessive load was applied [00:14:00] or a rapid change in direction. of those two angles, so I've seen it in athletes you know, various injuries, right? Athletics is one of those things that it's like, it's often like a motor vehicle accident. Um, especially if it's a sport that somebody runs into a wall or gets hit by another athlete or jumps on one leg or lands on lot in one leg, right? There's a lot going on in there.
[00:14:29] The other time I've seen it is sort of like a, um, chronic. asymmetrical loading like that over time and then sort of straw that broke the camels back, but in every scenario it was the side that moved too much causing the pain, and once I could get the side, that wasn't moving at all to move a little bit, their pain decreased significantly or completely.[00:15:00]
[00:15:01] Or even when I could help change the orientation of their pelvis to inherently restore the stiffness of the SI joint ligaments, their pain goes away. or stop driving excessive motion through the SI joint. So some other incidences that you'll read in the research and I've seen in my practice is that someone has a pathology at a joint around the SI joint.
[00:15:32] So they have a hip joint pathology, like a labral tear or hip arthritis. So they have stopped rotating and moving through their hip. And so all the motion is now being driven into the SI joint causing this repetitive sort of overuse type of scenario. Another one that you see in the research is people with, [00:16:00] lumbar fusions, so post lumbar fusions and they can't really move a lot in the lumbar spine.
[00:16:06] In flexion extension or rotation. And so they start moving a lot in their SI joint and again, cause excessive movement. Uh, typically those two in these scenarios we see that one SI joint moves too much and then the other one is not moving at all. So if we can get those, you know, treat the joints with the actual pathology and then get the one side of the SI joint, that's hypomobile to move.
[00:16:35] Then we often decrease the pain at the hyper mobile side. So this conversation too about pain being driven in the SI joint, that is moving too much is always, is ironic to me in a sense, because oftentimes what you hear, um, [00:17:00] From vocal people in the industry on the internet, is that the si? Some people would argue that the SI joints don't move at all, right?
[00:17:09] Like the, the amount of movement is so minute that you can't even count it as movement. But then oftentimes when you look at the common treatment protocols for people with SI joint pain, the common treatment tells you. That you need to stabilize the SI joints. So if you think of the words stabilize and stability exercises, it's usually because something's moving too much.
[00:17:36] So then it's like, well make up your mind. Is the SI joint moving too much or not moving at all? Should it move or should it not move at all? Right? So, um, whenever you see things that, um, like clash with each other, like. . To me that's a good indication of people just don't know what's going on and so they're making shit up [00:18:00] and um, that's fair.
[00:18:03] I was probably one of those people once upon a time, but now that I can understand the anatomy a little bit better now I'm like, oh, this makes so much more sense.
[00:18:15] Let's take a breath.
[00:18:21] So one of the other interesting things when you look at SI joint pain patterns, the SI joint pain patterns are a good indication of just how many. Ways that the SI joint is influenced by the other parts of the body. And that is cool, right? Because like I said at the beginning of this, I said one of the reasons why I love looking at the SI joint so much from an assessment standpoint is because it's literally connected to everything and influenced by everything.
[00:18:57] So I no [00:19:00] longer look at an SI joint that's hypomobile, right? That's not moving and think I need to do treatment to that joint to get it to move, I think. Hmm. Where's the information coming from? That is basically put that joint in a little bit of a protection pattern and doesn't allow it to move at all. And so then we, that takes us back to the nerves.
[00:19:23] I've talked about this, I think I talked about this in the thoracic outlet syndrome podcast, but when. See a muscle that it has increased tone or you know, some people would describe as being tight instead of beating the shit out of it with deep tissue massage or, um, some sort of, Yeah, forceful thing.
[00:19:47] I take one step back and I think about what nerve is innervating that muscle and where is that nerve at and is that nerve free to move within its fascial spaces or bony spaces, to then [00:20:00] function, give the correct information to the muscle. Same thing goes with joints. So I look at the joints and I take one step back and I think,
[00:20:09] what are all the inputs from those nerves? Are those nerves free to move and act and do their part? That's a quote from at still. Um, and I treat the nerves. And then does it change the joint mobility? If you treat the nerves or things associated with the nerve that innervates that joint and it changes the joint mobility, then it was never a structural problem.
[00:20:34] The hypomobility was not structural. The hypomobility was strategic. All right, let me say that again. If you treat a nerve that innervates a joint and it creates a reflexive change in joint mobility, it makes a hypomobile joint now mobile, then that joint [00:21:00] was not structurally immobile. If the joint is not structurally immobile.
[00:21:08] my argument would be, does it need to be manipulated? Does it need to be mobilized? Do we need to force mobility in that joint? If it changed, if the, if the reason it was not moving into the first place was strategic, probably not. All right? So when we look at the anatomy of the SI joint, we look at the nerves that innovate the si.
[00:21:37] The obturator nerve, the lumbosacral trunk, the nerve to the quadratus femoris. That's the actual name of it. Um, spinal nerves that come out of the sacral plexus and the superior gluteal nerve. The [00:22:00] interesting thing about the obturator nerve, the obturator nerve, we. innervates the hip joint as well, the knee joint as well as the skin, on the inside of our thigh, about halfway down our thigh and the adductors., right?
[00:22:22] The other thing, probably much lesser known, I didn't know this until recently. The obturator nerve also is one of the nerves that innervate the parietal peritoneum, so it is a nerve that is significantly influenced by visceral restrictions and visceral inflammations, visceral interception, basical.
[00:22:51] and also the changes and pressure of the entire visceral space. Even though the obturator [00:23:00] nerve only innervates the peritoneum in the lower part of the peritoneum, the entire peritoneum is attached. So even if I have an issue up at the upper part of my abdomen, it's reflexively still going to affect the lower part of my peritoneum..
[00:23:18] and give a message to the ator nerve about that, right? And oftentimes those messages get murky to the spinal cord and the brain, where they're coming from. And so all of the joints, all of the muscles that relate to that nerve or that nerve plexus oftentimes are. Okay, so the obturator nerve relationship is how the viscera one, one of the ways, not the only way, but uh, one of the main ways the visceral organs are related to the SI joint.
[00:23:57] The other way, the visceral organs are related to the SI joint. [00:24:00] Well, many of them sit right in the bowl of the pelvis, right in front of the si joint. Many of those are also sharing innervations from the sacral spinal nerve from the lumbo sacral trunk, right? The lumbosacral trunk is a big, um, Trunk of the lumbar plexus and the sacral plexus, that becomes the sciatic nerve, so it becomes the tibial nerve and the common peroneal nerve.
[00:24:33] So now we're looking at, this is gonna influence again, the hip joint, the knee joint, the hamstrings, the calf, the foot, the ankle, the tib. The entire low extremity. This is often why we see that when you do some sort of treatment to like the ankle joint, we'll say it changes your [00:25:00] SI joint function and this is that.
[00:25:03] That's the reason because they share a common nerve, so they share information, right? So, This is also when you look at the referral patterns of SI joint pain. This makes sense, right? So a common spots is right above the right, above the SI joint, um, posterior hip. Right? Makes sense. That's gonna be the cutaneous nerves in the area with the cutaneous nerves. Share the relationships at the sacral plexus with those spinal nerves. Pain's also going to often be on the sacrum itself. Spoil alert if pain is on the sacrum and is related to the SI joint. It's also always going to be related to a urogenital organ.
[00:25:57] Pain is often too in the [00:26:00] front of the belly, like lower abdomen, front of the belly. This is gonna be that again, the obturator nerve relationship. So the obturator nerve shares some roots with ilio hypogastric nerve, and that is that referral pattern in the front of the abdomen. , front of the hip, front of the thigh.
[00:26:19] Again, femoral nerve and obturator nerve. They share those nerve roots together. So that is a common referral spot down the lateral side of the hip and the thigh, like a sciatica type pain. Makes sense, right? Because of that lumbosacral innervation, you can even have pain down the outside of your leg into the outer side of the foot.
[00:26:41] Makes sense? Because the common peroneal nerve. So once you think about it, these very documented referral patterns basically points to all of these neural relationships to the joint, [00:27:00] and a little bit deeper understanding of the nerves. and the visceral organs allow us to see the connection to the visceral organs as well, as well as just the anatomy there.
[00:27:10] Then within the SI joint two, we have all these fascial connections, so we have the deep fascial connections of the containers of our abdomen, from our base of our skull to our pelvic floor. All of this fascial container is connected, so even cranial issues, tensions at the central nervous system in the cranium are going to be reflected down at the SI joint.
[00:27:35] In addition to when you think about the central nervous system, the central nervous system is the brain and the entire spinal cord. Where does the spinal cord end? Lumbar spine. Where does the filum terminale end. It goes from the lumbar spine all the way to where the sacrum!. Right into the tailbone, the sacral hiatus.
[00:27:58] If there is [00:28:00] cranial tension, the entire spinal cord, the entire spine, including the sacrum and the tailbone, will go into a pattern of side bending to relieve tension in the cranium. This is going to what? Cause one side of the SI joint to not move very well and drive more motion through the other side. This is just physics of having multiple segments, right?
[00:28:29] This is the relative stiffness concept that Shirley Sahrmann introduced to us. You know the, if you think about the body as being made of springs, if you tighten one up and don't allow a lot of movement, what happens? The other one gets more stretched out. It's exactly what happens when we have a hypomobility on one side.
[00:28:50] No wonder people start having symptoms of SI joint pain because now one joint is moving too much and when that joint moves too much, [00:29:00] remember all the nerves I listed out, those are all the nerves that are getting these mixed messages. So, , I would, I would be doing you a disservice if I didn't talk about how to assess pain versus assessing mobility. Like I said, the results cheat code, and in the ltap I assess SI joint mobility. That gives me the information I need to know if it's being driven by the viscera, the central nervous system, or the peripheral nervous system, or the musculoskeletal system.
[00:29:34] However, if I'm trying to help in diagnosing, , someone's injury, someone's pain, or direct them where to go. If my treatment's not helping them the way that I can be sure their pain is coming from the SI joint, specifically a hypermobility causing pain. I need to do a series [00:30:00] of tests to confirm pain provocation at the SI joint in the research, the research tells us that not just one test is adequate to point to the SI joint as the pain generator, but it needs to be a cluster of tests.
[00:30:17] So there's five tests that you can choose from. They're like, your classics like FABERS tests, like the thrust test, the compression test, the sheer test, and then Gaenslen's sign, and I forget the other one, but three of five of those need to be positive in reproducing someone's pain in order for it to be sure that the pain is coming from the SI joint and not somewhere else.
[00:30:47] Because as you can see, , there's many other things that have similar pain referrals.
[00:30:53] I'm gonna probably. wrap it up there. Is that all I have to say [00:31:00] about the SI joint? No, there is still so much more to say, but it starts to get your mind thinking about it in a different way than you have probably thought about it in the past. But just knowing that when I'm thinking of the SI joint, you know my, my sort of core beliefs about the SI joint is that it should move.
[00:31:24] I firmly believe that we are made the way we're made for a reason. If, if the SI joint wasn't made to move, it would not have been a joint. It would've been just like a circular type of bone. It is made to move. It's part of our unique locomotion as a human being. Our bipedal, rotational locomotion. A SI joint that moves in different ways, right?
[00:31:58] So core belief number one, [00:32:00] the SI joint should move core belief number two, SI joint in general is misunderstood, and when it's misunderstood, it means it's sort of often treated in a way that doesn't make sense with the anatomy and doesn't make sense with your assessment. Core belief number three about the SI joint is that it's connected to everything visceral, neural, fascial.
[00:32:38] Therefore, it can give us a lot of information about those systems and the influence, influence of those systems on SI joint function. Going back to the first core belief of it, it should move in. Its in, its what? What [00:33:00] part is? Part of what makes humans unique is that, , it is an important assessment to do to look at movement and function of a human being.
[00:33:16] So you could call that core belief number four if you want, um, or you just could include it in number one. But I think, I don't think many people would disagree to me that the SI joint is important and make is what makes us uniquely human and what makes is part of what makes our movement so unique. But it's just the confusion about, about the joint and the joint function in itself is where we need to clean things up.
[00:33:46] And then also the confusion about the research of the joints. I would argue that the research is not very good for looking at the joint mobility [00:34:00] is. , A lot of people don't trust their hands, what they feel, and they're confused about what they're looking for. And also because this joint is, is influenced very much so by the viscera and the nervous system, it mucks up a truly orthopedic, biomechanical, musculoskeletal research.
[00:34:32] Paper or a research project because since this joint is influenced by the viscera and the nervous system, it's going to often move and not move even within the same day. Potentially. And so perhaps part of the reason why the interrater and intrarater reliability on some common SI joint mobility test isn't great is [00:35:00] because we don't understand this role that the viscera and the nervous system have on it.
[00:35:06] And so that's really what I share within the results cheat code and within the ltap is a different way to look at these mobility tests. so we can more clearly see these visceral and neural connections. So that's it. Um, don't worry. I will record more podcasts about the SI joint. I am 100% sure and I hope that if this interests you, you will join me in the Results cheat code coming up.
[00:35:38] I do offer it twice a year. It is FREE and it is a six day live online course, and I would love to have you there because I would love to have you practice an old orthopedic assessment in a new way to see just how powerful it could be. [00:36:00] Thank you for joining me. I'll see you next week.
[00:36:04]
