Sacroiliac joint fusion and the implications for manual therapy diagnosis and treatment.
^{Man Ther. 2008 May;13(2):155-8.}

Dar G, Khamis S, Peleg S, Masharawi Y, Steinberg N, Peled N, Latimer B, Hershkovitz I.

Dear Dr. Gali Dar,

I am pleased to have you join our member of the Sacroiliac Medical Expert Group (SIMEG). My interest in the SIJ originally came from manual therapy practice, so I am excited about discussions like this.

In Japan, we have a manual medicine society known as the Arthrokinematic Approach (AKA) - Hakata Method, which includes both physicians and physical therapists. Orthopedic surgeons tend to rely too heavily on imaging findings for diagnosis, often overlooking physical abnormalities when images do not show clear abnormalities. The society advocates for the recognition of the difference between imaging findings and actual functional impairment and asserts its influence on the medical community.

At one of the AKA conferences, I presented cases of severe osteoarthritis (OA) and spondyloarthritis of the SIJ. I argued the importance of considering imaging results, especially in refractory cases with abnormalities, and suggested that pathologic classification should not be based solely on response to manual therapy, but should also consider other treatment modalities. Despite my intention to have a scientific discussion, the senior physicians denied the relevance of imaging to symptoms, which I still clearly remember

The field of manual therapy, even when practiced by physicians, can be exclusive and dogmatic. As you mentioned, once the SIJ is fused, joint mobilization treatments are inappropriate. Even after SIJ fixation, manual therapists may still incorrectly diagnose the joint as loose, raising concerns about the possibility of a genuine discussion based on a common understanding. Such statements can also damage the trust between manual therapists and orthopedic surgeons.

Based on the findings of this paper, is there a consensus among you not to perform manipulation or mobilization on elderly men with SIJ bony fusions?

In addition, could the shape and location of osteophytes provide insight into the patient's condition? For example, the anterior superior portion of the SIJ often develops marginal osteophytes, and traction spurs are also seen on the sacrotuberous ligament at the ischial tuberosity. These observations may indicate prolonged over-nutation of the sacrum in daily life. Occasionally, curved traction spurs develop at the posterior caudal aspect of the SIJ. How do you apply these findings in clinical practice? Please share your findings if you have.

Daisuke Kurosawa