I decided to write this report as a result of a fellow colleague exchanging some strong beliefs on his blog about his views on Tiger Woods medical team using incorrect terminology regarding what happened to his sacro-iliac joint (you can read his blog and comments here). The comments on his blog highlighted common misconceptions about ‘mechanical’ back pain and pain science.
It is well documented that the sacro-iliac joint (SIJ) pain is very common (reference, reference, reference, reference) The same evidence highlights a poor relationship between studies regarding the source of symptoms in the SIJ.
The SIJ is an extremely stable joint made up of a fibrous joint posteriorly and a synovial joint anteriorly. The sacrum and ilium have rough articulations in order to create that which resembles a locking mechanism. The SIJ is held together by 7 very strong ligaments, some of which have extensions into the the erector spinae muscle group, thoracolumbar fascia and posterior sacrotuberous ligament, meaning it has an extra cover of strong tissue over its sacral surface connecting the top of the SIJ to the bottom. This is termed form closure. Thus the SIJ has been shown to have between 3-5mm of movement (reference), supporting the theory of its main role as a weight-bearing joint designed to absorb or transfer energy between the upper body to the lower body (reference). This is termed force closure. Including overlying fascia communicating with muscles this all makes for an extremely stable joint.
It was claimed that Tiger’s sacrum ‘popped out’ and with a quick manipulation it popped back in again
Now I am in complete agreement with the clinicians that expressed their disgust regarding the statement that Tiger Woods released. This just does not happen. Interestingly the evidence suggests that the complexities of SIJ anatomy and biomechanics question the manipulations that health professionals claim to use are to simplistic (reference). So manipulation for an SIJ cannot be regarded as an effective treatment (pseudo-science I think the term is here). Use of language such as a sacrum being popped back in can create the belief that there is something structurally wrong and the only way to fix this is through manipulation or even surgery.
The sacro-iliac joint can be a source of pain, however I would suspect that this is due to the process of nociception from dysfunctional tissue that crosses the sacro-iliac joint. It is not due to laxity in the joint, the research supports this. It is important to point out that there is evidence to suggest that sports athletes and post partum women are more susceptible to sacro-iliac joint pain and/or pelvic girdle pain (reference, reference) but it is clearly stated this is not down to laxity or because of sacrums popping out. In the case of Tiger Woods there were pertinent co-morbidities, in particular low back pain, which he underwent surgery for. If it were that easy to resolve back pain with a single manipulation then I would be a very rich man and be somewhat ignorant of evidence based practice.
The tale of two tales
There are many members of the public and in the health professional world that still think that pain exists in the tissues and still think with a bio-medical approach/perspective. I don’t dispute this approach but not having an understanding of pain mechanisms in my opinion is creating a disservice to the public. As health professionals a first rule is do no harm. Passive therapies work in the short term but the buck steps there. Continuing with these approaches actually break this rule creating a “dependency syndrome”. I use manual therapy in my practice everyday so I’m not saying I don’t use it. However understanding and educating patients in pain science and the biopsychosocial approach is crucial to recovery (reference). Particularly those that have suffered with long term pain. Pain is a multi-factorial experience and context is a pertinent aspect. Let me explain:
Tiger is an international golfer, well respected in the golf scene and one of the best golfers of his time. There is an immense amount of pressure that hangs on him. Playing any high level sport places a lot of physical and mental strain on the body and the expectation is that you are out to play the best game of your career every time. The public wants it, the media wants it, the medical and coaching staff want it and even Tiger wants it.
When we suffer a physical injury the tissues need to be addressed without a doubt. Yet there are other factors that we need to consider, particularly cognitive factors i.e. we are concerned about what it is? why it happened? will I recover? will it get worse? will I ever play again? what will this do for my career? It goes further than that too. Questions such as why is it not getting better? why can’t the healthcare system help me? all gives rise to the pain experience.
The point of the blog was to highlight the medical professionals (rightly or wrongly) using incorrect terminology to describe what potentially happened to Tiger’s SIJ. It demonstrated a strong message from the clinician about his beliefs and evidence based understanding of the SIJ. It also created a strong response with some clear comments about how angry and let down some individuals are by the healthcare system and most likely being misinformed by several healthcare professionals that were unable to give a credible reason for their symptoms . To me this highlights the importance of getting the correct advice and health professionals maintaining their professionalism in line with evidence based practice. Read my post on the dark side of chronic pain here
I wrote this post as I felt it was important to highlight the poor use of terminology used and the misconceptions that it can create to those individuals that suffer from long term pain. In addition to dispel the misconceptions around pain science and to discourage the stigma behind it ‘all being in your head’. Finally to emphasize that when structure is affected function (neuromusculoskeletal system) needs to be optimized to reciprocate it.
Thanks for reading, your comments, opinions are always appreciated.