The alignment issue. Are your back and hips really out of alignment?

I know I’m heading into deep water over this one, but I feel it needs to be talked about.  Have you ever been told by your physical therapist that your back and/or hips are out of alignment?  And I’m not discussing this to bash on chiropractors at all.  I would say a vast majority of physical therapists deal with this issue as well, so this is squarely directed at our profession.  There are many times when your back or hips (or more specifically your pelvis) are a little off and need some TLC.  But have you ever been told this when the area isn’t bothering you?  Or have you been told this after the therapist palpates your back and determines that it’s out?  These are sticky areas that deserve some discussion.

First of all, there are some good clinical tests out there that can determine if your pelvis or vertebrae are stuck, not moving correctly, etc.  These tests involve you getting put into some funky positions and trying to provoke pain and determine mobility.  Testing such as these are pretty accurate.  What I am concerned with is when I see a therapist poke around your back or pelvis a bit, compare how a bony landmark looks on one side compared to the other and state your back is a mess without doing any other type of tests.  So why does that bother me?  Let me tell you.

The only part of your back that we can accurately palpate is the little bony tip of the vertebrae called the spinous process.  You can usually see these easily when you ask someone to bend over and touch their toes.  I’ve seen therapists palpate the spinous processes, comparing how one lines up compared to the one below it and so on.  If a spinous process doesn’t line up they declare that vertebrae to be rotated to the right or left.  The problem is that our spinous processes do not always grow straight out from the rest of the vertebrae.  Some with slightly lean right or left or even up or down.  This can be do to a variety of factors including how various muscles may pull on the vertebrae.  So sometimes the spinous process can make it look like the vertebrae is not aligned when in reality it’s in the perfect position.

Another common issue I see is palpation of the Sacroiliac joint, or SIJ.  This is where the tailbone articulates with your pelvis.  We have two SI joints and they are located near the small of your back.  Most of us have two dimples in our low back.  The SI joint is pretty close to the dimple.  There is a pretty big bony prominence that can be palpated at the SI joint.  For many years the therapist would palpate each SI joint and compare right to left to see if the bony prominences were equal.  If they weren’t it meant one or both of you SI joints was out.  Now a lot of PTs still do this and I’m not saying they aren’t doing a good job.  However, if this is the only diagnosing tool they are using then they could be missing the mark big time.  Here is what I’ve learned about the SI joint.  There are over 80 clinical tests used to diagnose a SI joint issue.  What does that mean?  It means none of them are very good.  If there was a good one out there, there wouldn’t be so many tests.  In the knee there are only a couple of tests used to diagnose an ACL tear.  There are only a couple because they are good ones, so there is no need to try to come up with another.   There is a study in which 10-13 experts in orthopedic palpation (doctors, PTs, surgeons, etc) palpated the SI joints on several patients.  They each did it independently of each other and came up with their own diagnosis.  They were all different.  There are MRI’s of people’s SI joints that show huge differences between the two, yet the subject had no SI joint or low back pain whatsoever.  What all this goes to show is that the SI joint is a tough one to get right.  Palpation alone is not very accurate.  Provocation tests (where you try to reproduce the pain) have been shown to be more reliable.  I only use provocation tests for the SI joint.  I don’t palpate the SI joints for mobility at all.  It’s not to say that they can be palpated, but if that is the only test being done I don’t know how accurate the diagnosis will be.

Be that as it may, if therapists palpate your back in the ways I’ve mentioned above it doesn’t mean they aren’t doing a good job.  However the information gathered from the tests needs to be formulated with information gathered from other tests to come to an accurate diagnosis.  But as stand alone tests I would say that they can’t be trusted.

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