Assessing the Sacroiliac Joint: The Best Tests for SI Joint Pain

SI JointThe sacroilliac joint, or SI joint, is one of those challenging areas of the body that we all have to deal with from time to time.  When I learned how to assess the SI joint, I know that I felt like I didn’t have a firm grasp on the best way to test for SI joint pain.  Many of the commonly performed assessments for SI joint pain seemed to not be very reliable and sometimes not even valid.

So treatment almost sometimes became taking a shot in the dark as I never truely felt confident in my exam findings.  This led me to perform treatments and progressions of patients based on trial and error rather than because of exam findings.  (Photo from Wikipedia)

Assessing the Sacroiliac Joint

Treating this way, to me, is a huge pet peeve, so I started to research the area to gain more comfort in my SI joint examination.  I found some interesting research regarding palpation, SI joint motion, and provocative testing.  Here are some of the things that I found along that way that really helped me get better at diagnosing SI joint pain, hope it helps you too.

Palpating the SI Joint

One of the simplest methods of assess the SI joint is palpation.  However, the reliability and validity of palpating the SI joint has come into question in recent years.  Several studies have been published showing poor inter-tester reliability for static SI joint palpation, including a nice study from Holgren and Waling.

McGrath has published an interesting article, entitled “Palpation of the sacroiliac joint: an anatomical and sensory challenge” in which the concept of SI joint palpation is scrutinized.  It is an interesting paper, that certainly makes you think.  In the paper, the author describes the several layers of tissue that sit between the skin and the posterior SI joint, which is 5-7cm deep to the skin, and the inherent challenge of both reliability and validity of palpating something so deep.

Assessing SI Joint Motion and Symmetry

Assessing the amount of SI joint motion and the symmetry of the SI joint itself is a very commonly performed technique during SI joint examination.  This method of examining the SI joint is popular and accepted, despite the lack of research supporting the technique.

Based on the above information regarding palpating the SI joint, one would question the ability to palpate AND now accurately assess motion in addition.  If palpation has poor reliability, this automatically makes assessing motion difficult.

Freburger and Riddle performed a literature review looking at our ability to perform SI joint motion testing.  They found poor inter-tester reliability, low sensitivity, and low specificity in several commonly performed tests.  This is a particularly interesting article to read if you have interest in this area.

Another study from Robinson et al had similar conclusions, stating that SI joint motion palpation tests have poor inter-tester reliability.

Riddle and Freburger in another study noted that the ability to detect positional faults of the SI joint also has poor reliability.

Thus it appears that the reliability and validity of assessing SI joint symmetry and motion may be too poor to be used clinically.  The amount of motion of the SI joint motion is extremely small, perhaps less than 2mm and 2 degrees of translation and rotation.  This makes detecting patholgoical movement extremely challenging.

However, I still think symmetry and motion assessment may be a valuable component of the SI joint examination in the case of significant malalignment and pathology, and still should be assessed.  Just realize that you are looking to “rule in” more significant pathology.  I would not “rule out” SI joint dysfunction based solely on symmetry and motion assessment.

Location of SI Joint Symptoms

Van der Wurf et al (2006) published an interesting study looking at the location of symptoms reported in patients with SI joint pain and dysfunction.  In the study, the authors performed local SI joint injections to block the patients’ pain.  The authors found that:

  • All subjects that responded to the SI joint block had symptoms located at the Fortin area (3cm horizontally by 10 cm vertically inferior to the PSIS)
  • All subjects that did NOT respond to the SI joint block had symptoms at the Tuber area (just inferolateral to the ischial tuberosity)

Again, I wouldn’t rule in or rule out SI joint dysfunction based on this alone, but it appears that if you DO have pain at the Fortin area AND do NOT have pain at the Tuber Area, you may be experiencing SI joint pain.

SI Joint Provocative Tests

Two recent studies by Laslett et al and Van der Wurff et al have demonstrated that there probably isn’t one perfect SI joint provocative test that we can perform to definitively diagnose SI joint pain or dysfunction.  Basically, there is no “gold standard” such as using the Lachman test for ACL tears in the knee.

However, by performing several tests together, you can increase your sensitivity and specificity of detecting SI joint dysfunction.

Combining the two studies, there are 5 provocative tests to perform when attempting to diagnose SI joint pain:

  1. Gaenslen
  2. FABER / Patrick’s test
  3. Thigh thrust / femoral shear test
  4. ASIS distraction (supine)
  5. Sacral compression (sidelying)

Laslett et al report that the accuracy of detecting SI joint dysfunction is increased with at least 3 of the 5 tests are positive.  Furthermore, if all 5 tests are negative, you can likely look at structures other that the SI joint.  Van der Wurff et al report that if at least 3/5 of these tests were positive, there was 85% sensitivity and 79% specificity for detecting the SI joint as the source of pain.  Interestingly, another study by Kokmeyer et al agreed with the previous findings, but also noted that the thigh trust test alone was almost as good at detecting SI joint dysfunction as the entire serious performed together.

It seems like performing a series of provactive SI joint tests is better than one true test in isolation, though I would specifically emphasize the thigh thrust test.  In my experience, you have to use a decent amount of force during the thigh thrust technique to avoid missing a positive provactive sign.

In an attempt to find good demonstration videos on youtube of these techniques, I came across Harrison Vaughn’s excellent videos (I mentioned Harrison in the past and recommend you also check out his website).  Great job and thanks for sharing Harrison!  These are the tests recommended by the above authors to use together:

Gaenslen Test

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FABER / Patrick Test

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Thigh Thrust / Femoral Shear Test

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ASIS Distraction

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Sacral Compression

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The Best Tests for SI Joint Pain

I will admit that I am not a SI joint expert, so I am interested in hearing the opinion of my readers that deal with a lot of SI joint dysfunction.  It appears that palpation, symmetry, and motion testing of the SI joint may have concerns in regard to reliability and validity.

Some things to keep in mind when assess the sacroiliac joint:

  • It is difficult to palpate the deep SI joint, making reliability and validity challenging
  • The reliability of assessing symmetry, SI joint motion, and SI joint position also has poor reliability
  • Pain along the Fortin Area without pain in the Tuber Area may indicate SI joint pain
  • A series of provocative SI joint tests yields better results that performing tests in isolation, with at least 3/5 positive tests demonstrating the highest accuracy of detecting SI joint dysfunction

Based on some of the research above, we should all consider the location of symptoms and a series of provocative testing when attempting assessing the sacroilliac joint and diagnosis SI joint pain and dysfunction.

 

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36 Responses to “Assessing the Sacroiliac Joint: The Best Tests for SI Joint Pain”

  1. Mike,
    Nice post. Just one small thing…Laslett’s article also included a prone sacral thrust test which was included in one of the cluster diagnoses. He stated that 3 out of 4 provocation tests (distraction, compression, thigh thrust or sacral thrust) demonstrated a sensitivity of .88 and specificity of .78. But like you showed with this article, using a cluster of diagnostic provocation tests will increase our likelihood of differentiating the SIJ from other parts of the body (we should also rule out the lumbar spine and hip prior to assessing the SI joint)…Nice post

  2. Russell Manalastas Reply March 12, 2012 at 9:14 am

    I do refer to Laslett’s cluster of tests to determine SI involvement but like Joe mentioned above, I’ve often come across patients with L5-S1 joint involvement because of the close proximity between the L5-S1 facet and SIJ so ruling out Lumbar/Hip is key. Also I think the SIJ can be overemphasized sometimes when patients present with pelvic asymmetries/obliquities when there is only a small amount of total motion at the SIJ. Thanks for the post Mike.

  3. I still find it interesting that there is no agreement whether the SIJ even moves after adolescence (besides during child birth and when relaxin is circulating). I recently took a Sahrmann course and asked her on the side about SIJ dysfunction. She just laughed and said “doesn’t move.”
    Two additional tests I’ve been taught are the prone knee flexion test, and a AP/lateral glide of each ilia. This test helps differentiate asymmetrical bony landmarks. By slowly ramping up force, you will either feel a smooth glide or an abrupt stop prematurely. That is then considered the dysfunctional side. Ex- R ASIS higher, R PSIS lower. Which side is dysfunctional??! Could be a relatively LOWER L ASIS- glide both to decide the side of dysfunction.

  4. Nice post Mike. Always good to read your stuff and see what you find interesting out there. For those who have not read the book “The Essential Role of the Pelvis” edited by Vleeming and Mooney, its worth reading to understand where we are coming from. There is obviously a lot more work that has since been published but it’s one for the library.

    Best
    Chris

  5. very nice n interesting demo.but i would also like 2 knw wther SI jnt can b dislocated if so r der any special tests dat show +ve results n also let me know d differential diagnosis of d jnts involved(hip,knee,SIjnt). thanku..

  6. Thanks for the link back to videos Mike! I’m hoping combination of several blogs are finally educating others to use provocation tests mainly, rather than the old school position testing (and using gillet, long-sit test, etc) as the diagnostic values of these tests are quite poor for helping to rule-in SIJ involvement. Good research is out on a very difficult region. Great information as always!

    Best,

    Harrison

  7. When looking at the sacrum you always have to look at L5 as well. They should move inverse to one another. When patient’s subjectively indicate to you they have trouble with transitions or pain with bending or extending it can stem from the L5 being stuck in a flex or extended position or the sacrum flexed or extended. The sacrum also can have torsion problems which can create unilateral leg pain with standing or sitting. The Jones Institute for SCS does a excellent job in teaching this as well as instructing clinicians in evaluating this and providing simple manual treatments which restore this inverse relationship. Then work on the asymmetry found in the reminder of your examination.

  8. I often follow up with some of Brian Mulligan’s manual techniques for the SI joint. If I cannot decrease the symptoms with one of these mobilizations, I have to seriously question whether SI path is the problem.

  9. The joys of the SIJ and pelvic girdle never cease. Thanks for the post and starting the discussion.

    One key item to be clear on, SIJ dysfunction and Sacroiliac Joint Pain. We must use the appropriate language so that our clinial reasoning and professional conversations within the health care community can be more accurate.

    Dysfunction can indicate hypomobility, hypermobility or poor movement patterns about the joint. Pain of the SIJ, many refer to as “sacroilitis” is something related, but often very different. We MUST speak the same language.

    A continued hot topic is classification of low back pain. Non specific low back pain studies are not very helpful as there are many flavors of dysfunction, we all know that. Just like shoulder pain has many different causes besides a rotator cuff tear and/or a frozen shoulder.

    We may need to consider some different classifications for SIJ pain &/or dysfunction. Whether we can measure these or not in 2012, doesn’t mean they don’t exist. The SIJ is joint that moves, transmits forces (a lot of them) and has muscle and fascial connections, and is ultimately controlled by the CNS. JUST LIKE ANY JOINT. Because it is a joint just like any other, let’s categorize the problems with it like we would any other joint.

    1. HYPOMOBILITY: You may have a frozen shoulder that leads to neck pain. Just like a stiff SIJ can lead to back or hip pain, etc.

    2. POOR MOVEMENT PATTERN: The complexity of the SIJ cannot be understated, notably it’s direct interactions with the pubic symphysis, lumbar spine and indirect actions with the hip. So any dysfunctional movement pattern can lead to poor force transmission.

    3. HYPERMOBILITY/INSTABILITY: This may by associated with a poor movement pattern, or simply may not transmit loads effectively. Remember the density of the interosseous liagment. It is a tremendous force transducer. If it is lax, how does this affect the lumbopelvic-hip complex?

    4. SACROILITIS/SACROILIAC PAIN: All 3 above could be a cause of pain. As could an infection. There are over 100 different types of infections that can lead to sacroilitis. We cannot forget that. Salmonella is one relatively common one.

    The problem is, you usually have some type of combination of the above. Einstein said to keep things as simple as possible, but no simpler. In this case, classifying the SIJ as painful or not painful is very helpful. But this is just too simple. We must then attempt to classify and or subclassify further. In 2012, we have a long way to go. But a good place to start your journey is with the current concepts published by the Orthopedic section of the APTA.

    http://www.orthopt.org/162.php

    Again, thanks for the post and getting the conversation moving.

    Kris Porter, PT

  10. Kris and others,

    “Dysfunction can indicate hypomobility, hypermobility or poor movement patterns about the joint. Pain of the SIJ, many refer to as “sacroilitis” is something related, but often very different. We MUST speak the same language”

    I would agree. But, I think some of the current research and literature regarding pain generally, and the SIJ/pelvic region specifically suggest that attempting to classify hypo vs hypermobility may be a futile endeavor…

    “We must then attempt to classify and or subclassify further.”

    I am not sure classifying further is appropriate given what we know about the motion at the SIJ and the asymmetry in anatomy and movement that exists in non-painful, non-dysfunctional individuals.

    Lastly any classification or testing shoulder should assist in guiding treatment target or intervention components as well as result in superior outcomes. If not, we are classifying for the sake of classifying EVEN if that classifying is reliable.

    Recently Jason Silvernail and I wrote a letter to the editor of Manual Therapy (currently in press) addressing 3D modeling of the SIJ/pelvis. In addition, we discuss some of the issues here:

    http://ptthinktank.com/2012/03/18/si-joint-mechanics-in-manual-therapy-relevance-please/

  11. Kyle,

    I appreciate your thoughtful reply on this blog as well as your response to Manual Therapy (journal) in response to the Adahi et. al article reference in the link above. I agree, motion testing and symmetry assessment has serious validity and reliability concerns.

    Although I agree that testing of the SIJ needs improvement, I would not agree that attempting to seek a more accurate way to sub-classify SIJ pain and/or dysfunction is futile. In a 2011 study, we found that we still do not have a reliable way of assessing ankle dorsiflexion with a goniometer. But I still use this technique as it provides clinical utility for me. I attempt to carefully control variables such as force, subtalar position, and patient assitance in order to improve my intra-rater reliability. I also keep in mind the potential weakness and bias I may have with my measurement and rely on other clues to indicate a functional loss of dorsiflexion. I correlate this with gait analysis, squat performance, patterns of compensation in the midfoot, etc. (http://www.japmaonline.org/content/101/5/407.short). We naturally look for patterns and supporting/refuting information to make conclusions in the face of ambiguity.

    [I am not sure classifying further is appropriate given what we know about the motion at the SIJ and the asymmetry in anatomy and movement that exists in non-painful, non-dysfunctional individuals.]

    To continue the example, ankle DF restrictions often don’t present with pain, but they may over time lead to pain in the kinetic chain. If a patient self regulates their stride length or compensates well through the midfoot or elsewhere, this dysfunction could go on for years painfree. Just because a patient is painfree does not mean that they have serious issues with transmitting forces.

    [But, I think some of the current research and literature regarding pain generally, and the SIJ/pelvic region specifically suggest that attempting to classify hypo vs hypermobility may be a futile endeavor…]

    Of course we should always attempt to treat the “why”, or the key impairments leading to the tissue insult. So I agree 100% with your comments to Adahi et. al that our ultimate goal should be to find the impairments that may be leading to SIJ pain/dysfunction, even if we never touch the SIJ.

    However, this approach neglects some important points. There are conditions that clearly lead to SIJ hypomobility, which can be validated with diagnostic imaging such as ankylosing spondylitis. Additionally, I hope at this point we can all agree that hypermobility of the SIJ and pubic symphysis exists, notably in painful populations for pregnant/post-partum women and or in cases of trauma. Finally, the knowledge of pain by itself is helpful but can be dangerous if treatment paradigms are designed based on this. What if the patient has an infection, or a stress fracture?
    Good therapists are classifying already whether they know it or not.

    Great discussion Kyle! It was nice to meet you at CSM.

    For those that actually read this far, I’m sorry for the length.

  12. Mike,

    Excellent SI joint presentation and comments.

    I agree that the SI joint is difficult to understand and to determine as the source of pain. I also agree that the SI tests are not the most definitive or scientific, however a patient who has positive provocative test and a negative LS exam should have the SI joint R/O as the origin of pain.

    Studies are indicating a higher percentage of pain below L5 maybe originating from the SI joint. A study by Jonathan Sembrano MD, “How Often Is Low Back Pain Not Coming From the Back” and another by Kee-Yong Ha MD, “Degeneration of Sacroiliac Joint After Instrumental Lumbar or Lumbosacral Fusion?” suggest that 15-25% of their population studied with LBP was found to have the origin of pain from the SI joint.

    The concept of Adjacent Segment Disorder is suggested due to the transference of forces inferior to the lumbar spinal fusion to the SI joint.

    Physical Therapists are in a key position to assist in the orchestration of care of a patient with chronic SI pain.

    The recommendation of SI joint injections maybe indicated. The injections may stop or control the patient’s pain, thus confirming the SI as the source. If the pain persists a surgical spine consult maybe indicated. A fairly new SI joint surgical fusion procedure (the West Coast has been performing this technique for a few years) which is very effective, minimally invasive and with minimal disruption of a patients daily activity, may be the action of choice. The procedure requires three triangular titanium porous plasma coated implants.

    There is still a lot to learn about the SI joint, but I encourage the PT profession to embrace the concept of being the identifier of SI joint problems and the clinician source of recommendation to consult with other medical practitioners who may be of help in the care & treatment of the patient.

    I too wish to keep this conversation going and welcome comments and contact.

    Robert McKee PT MPA

  13. Kris,

    Thank you for your thoughtful reply. I think your examples of hypo (anklyosing) and hyper (post-partum) are very applicable, but for anyone NOT fitting into those two extreme ends of the mobility spectrum quantifying or classifying motion in this region does not appear to me to help us much with guiding evaluation, treatment, assessment, or outcomes tracking. In addition, I am not aware of any studies that illustrate that mobility or movement dysfunction in the lumbopelvic region (as defined and classified by a practioner such as a PT) in a non-symptomatic individual as predicting future risk for pain or symptoms.

    Maybe we should be classifying based on mechanisms based pain science? http://forwardthinkingpt.com/2012/03/01/mechanism-based-classification-of-low-back-pain-further-investigated/

    To quote Mosley as I did in our reply “equating pain to activity in nociceptors is seductive” And, I think attempting to correlate perceived movement dysfunction, hypo, or hyper-mobility to future or current pain problems is tough task also.

    Not only that, I am not sure it is relevant.

    If we are going to subgroup, the subgrouping should be:
    -Reliable
    -Valid (in this instance what we are classifying should in some logical way be tied to the pain or patient’s complaint…here again hypo and hyper-mobility and movement dysfunction does not seem to fit)
    -Effective
    -Efficient
    -Guide assessment, treatment, and outcomes tracking
    -Result in superior outcomes

    For the SI region, beyond pathological presentations (infection, anklyosing, etc) and gross hyper-mobility I am not sure further classification is warranted or useful. We currently have at our disposal more useful methods for understanding, classifying, and treating this region (and pain in general) which include an impairment based, provocation approach to assessment and a neurophysiologically informed, patient response dependent approach to manual and movement treatment.

    Lastly, I would hope PT’s are classifying if the patient may have pain that is medically pathologic in nature. I think that much should be assumed up front in the discussion of any painful region or population. This is the tenant of medical screening and determining the appropriateness of an individual for physical therapy, referral, emergent referral, or some combination.

    Thanks again Kris for you in-put and willingness to discuss! Your thoughts and discussion would be much appreciated on PT Think Tank post as well: http://ptthinktank.com/2012/03/18/si-joint-mechanics-in-manual-therapy-relevance-please/

  14. Great discussion! While I appreciate the Laslett study and instruct on those cluster of tests, I am not a fan of provocation testing unless it leads to treatment. Since the only assessment I do lead to treatment, I thought I would leave a quick bit for those interested in how I treat this area as well.

    It is easiest to use repeated motions to rule out the lumbar spine as a source of pain, and screen the hips for dysfunction. If repeated motions do not reproduce the lower back complaints, and the hips have normal mobility, the cluster tests can then be performed. As an earlier poster noted, a small percentage of individuals with lower back pain have a true SIJ pathology.

    In my 14 years of practice, I have only felt appreciable movement in patients who met the above criteria we teach in our fellowship program in teenage dancers/gymnasts (who easily scored 9/9 on the hypermobility scale). They required the SI thrust then stabilization with a belt and strengthening. Women who are 3rd trimester or late second trimester also benefit from a stabilization belt.

    Even if the patient perceives pain around the SIJ, very few meet the aforementioned criteria and can be treated with repeated motions/positions, non-specific lumbar manipulation, and manual therapy to restore hip mobility. At least 80% of patients with complaints in this area will respond to this or similar treatments. My classification for this area would be using MDT as a basis (which is reliable for classification), derangement or rapid/responder, or dysfunction/slow responder. Note, this is not to start a debate on the mechanisms of MDT, merely just using it as a classification!

  15. Great comments and feedback from very intuitive clinicians here! I would like to follow up with a few comments too.

    I highly agree that you need to rule out the lumbar spine and hips prior to really feeling confident that symptoms are arising from SIJ. I believe Laslett says you do but van der wurff no in this case, but makes sense to take an extra few minutes to perform repeated movements and mobility of hips (grind test).

    From a diagnostic standpoint, the values are till quite low in these studies; but actually not terrible for this very detailed and complicated area of the body.

    A recent example that I used these tests is with a gentleman who arrived at the clinic with back and leg complaints. For ease of this discussion, basically he was fused from L2 to S1 with 2 prior fusions over the past 10 years or so. His surgeon said his symptoms are arising from L1 and he can fuse that level but patient instead chose to come to us for PT.

    Knowing from adjacent segmental disease, very likely that either L1 or SIJ will ‘wear out’ quicker over time. I performed ASIS distraction and Thigh thrust with both positive responses of reproduction of concordat symptoms distal to L5 (the LR+ is just as good as all tests I showed in videos above). After telling patient my findings, he asked, “so the surgeon is wrong and you are right?”. Well, this made me step back for a second but basically I said yes.

    I was confident with these provocation tests (LR+ above 4) and made sense with back pain distal to L5, including adjacent segmental disease. I basically explained through surgeon’s “glasses”, he can fuse L1 to fix him but SIJ much more difficult procedure. Through my “glasses”, we can work on addressing hypo mobility and other impairments that I found on a clinical exam that both made sense to me and you. He was a type of guy who was hesitant to agree initially but wound up getting much better through conservative care.

    Hopefully that was not to long winded but my point came across.

    Harrison

  16. I am a new PT and was curious to find out ways you all also treat SI pain.

  17. Kyle (and others),
    I think it is clear from Kyle’s post that you are presenting a well rounded and evidence “enhanced” view of how PT’s should manage all conditions beyond just the SIJ, well put frankly:
    [We currently have at our disposal more useful methods for understanding, classifying, and treating this region (and pain in general) which include an impairment based, provocation approach to assessment and a neurophysiologically informed, patient response dependent approach to manual and movement treatment.]
    But back to the theme of this post on SIJ pain provocation tests. Pain provocation tests (of the SIJ or some other region) may help with patho-anatomic diagnosis (not the nature or the “why” the patient is there) and can be an indicator for tissue healing over time (are stress tests less painful). The cluster does not heavily guide intervention besides perhaps what things to protect/avoid, and whether a patient should receive an injection. Pain is a VERY limiting tool for prescribing interventions. I hope we aren’t spending much of our time pushing on painful tissue until it feels better. That makes very little sense, even if we have evidence to promote a placebo and substantial neurophysiological response. Even if we make the patient better doesn’t mean we prescribed the optimal intervention.
    Performance of this SIJ cluster is difficult to control vectors, forces and control for unique patient anatomy. Interpretation of these clusters is equally challenging. With multiple complex tests (with frankly marginal metrics) clustered together does not give us a great option here, we MUST recognize that. I still use the cluster, but very cautiously in the context of the whole person and the whole problem. Validation studies across different practitioners for more diverse patient populations will likely reveal different findings, but that’s ok. We are doing the best we can.
    I have been involved in teaching students at the University and Residency level and have seen many therapists get handicapped by this cluster and I have seen this cluster fall apart in the clinic day in and day out in my own hands and those of my experienced colleagues and younger residents.
    I suggest that we take a pragmatic and holistic view of managing patients with Pelvic Girdle pain. But I have a long sighted view of this issue. Do we give up seeking understanding of how to better understand the joint and rely on a shotgun approach to care? That will work for MOST patients. The master clinicians that manage the SIJ and Pelvic Girdle pain/dysfunction I can assure you do more than provocate the joint, and treat the impairments at the lumbar spine and hip and surrounding structures. Subtle and unique hypermobilities, and hypomobilites and movement pattern dysfunction exists even if we can’t agree on how to special test it.
    In the midst of difficulty lies opportunity. I look forward to seeing where the good research takes us. Kyle and others, thank you again. I am humbled by all of your wisdom, your energy, and your passion.
    My Warmest Regards.

  18. Jason Silvernail DPT, DSc Reply March 20, 2012 at 6:07 pm

    All-
    I think it’s important to point out that Laslett’s full clinical pathway for diagnosing SIJ-related pain included pain location and an assessment of the lumbar spine as well, it was not limited to purely provocation tests. The full article is well worth the read.
    Kris-
    I’m confused about a few things in your comments. You said “Pain is a VERY limiting tool for prescribing interventions.”  I really don’t understand your point here, or perhaps it’s just that I disagree with it. Maitland wrote two great books on the use of the “pain/movement” relationship to prescribe passive movement intervention and published randomized trials with good effect sizes in several body regions involve using his “impairment-based” method of diagnosis, treatment, and management. The MDT system also has a clinical reasoning method that uses pain responses to guide treatment and has good supporting literature. I think pain is a “VERY” useful guide to treatment in my practice.

    If we see these provocation tests purely as a pathoanatomic diagnosis then I agree it’s not terribly helpful – you could only then use it as a basis to recommend SIJ injection!
    But if you see these provocation tests as a movement examination with a painful response you could certainly use Maitland’s priniciples or other clinical reasoning methods to guide your decision making in these patients. I often use one or more provocation maneuvers as a treatment movement just as I would a PA mobilization or other movement. It certainly can guide your decision for thrust manipulation or SIJ belt use as well. I certainly agree that the test cluster and protocol Laslett uses or the IASPs recommendation for provocation tests aren’t perfect and Szadek et al do a great job of outlining some of the current clinical challenges in SIJ diagnosis (citation above).

    You said “subtle and unique hypermobilities, and hypomobilities and movement pattern dysfunction exists even if we can’t agree on how to special test it.” I would suggest you have this backwards. I submit that instead “subtle and unique hypermobilities and hypomobilities and movement pattern dysfunction have never been demonstrated and may be pure speculation and perceptual error on our part.” Perhaps there are these subtle changes of biomechanics that are relevant for individual patients but for whom we can’t design a relevant RCT for reliability, diagnosis, or intervention. I’m not opposed to clinical intuition or expertise but I think that expertise ought to be grounded in some plausibility first and that argument sounds suspiciously like “special pleading” to me.
     
    I would suggest also the cluster, when used as described by Laslett as one part of a pragmatic algorithm, only “falls apart” if we don’t fully appreciate its place in the overall complexity of clinical practice. Not an easy thing to teach, to be sure, but something it sounds to me like you appreciate quite well

  19. Great discussion everyone, I REALLY appreciate all the great insight! I love when everyone shares and discusses.

    We have a nice diverse group here, all adding to the discussion.

    My only contribution to the discussion would be to agree with Jason, Erson, and others that these “tests” for the SI joint we discuss in the post don’t give us any relevant info on how to proceed with treatment.

    The way is see it, i do think they help us zone in on what to examine further, for example differentiating if SI vs lumbar vs hip.

    That’s everyone for sharing!

  20. I am suprised to see that the Gillet Test and Active Straight Leg test are not one of the special tests used to rule in or out SI joint dysfunction.

    • These tests hold little if any validity and inter-examiner reliability and actually led to the basis of this good blog post and discussion. We all learned the movement/palpation based tests, but it appears they tell us little. If all of us performed the Gillets on a patient, 50% of us would think the pelvis is rotated anteriorly and 50% posteriorly. And this does not apprear to be a skillset that improves with courses or experience.

  21. According to a Cattley’s study Validity and reliability of clinical tests for the sacroiliac joint. A review of literature.
    the results showed: (1-4 reliable 5 to have high validity)

    1.Gaenslens,
    2.Thigh Thrust test
    3.Finger Point test
    4.SIJ Pain Mapping
    5.Thigh Thrust test

    Gillets Test, Patrick’s FABER and Sacral Thrust/Compression were considered invalid and unreliable

    Therefore wouldn’t it be best to utilize the Finger Point Test, SIJ Pain Mapping rather than FABER and Sacral Thrust/Compression?

    -Sam

  22. I realise that my comment comes late to a quiescent thread but I came across this excellent web site and the reference to my article about palpation of the SIJ region, and the attendant difficulties. I should also add here, that SIJ provocation tests appear morphologically confounded, that is, they may challenge other potential pain generating tissues in addition to the purported structure of interest. I think it is also worth bearing in mind that there appears no unequivocal or pathognomic SIJ pain. Patients in which a highly specific SIJ lesion exists (pyogenic sacroliitis for example) have non specific back pain. The presentation does not alert the examiner to the SIJ. Rather, it is later developing systemic signs and localised radiological findings that indicate the diagnosis.
    We (McGrath, Jefferey, Stringer) have recently published a further paper that advises of our pilot study using Doppler sonography to indirectly show the neurovascular medial and lateral branches of the dorsal sacral rami: International Journal of Osteopathic Medicine
    Volume 15, Issue 1 , Pages 3-12, March 2012. doi:10.1016/j.ijosm.2011.09.002 which I hope some of the visitors to this site may find of interest.

    Finally, from an antomical perspective, the SIJ is like a finger print – morphologically different between sides and between individuals. Solonon’s work illustrates this beautifully. It follows logically that motion is both highly variable and very small, given the functional requirements of the joint. Moreover, an MRI/histological study of the joint: Skeletal Radiol. 2004 Jan;33(1):15-28. Epub 2003 Nov 12.
    MR imaging of the normal sacroiliac joint with correlation to histology.
    Puhakka KB, Melsen F, Jurik AG, Boel LW, Vesterby A, Egund N. highlights the following: “The SIJ should be classified anatomically as a symphysis with some characteristics of a synovial joint being confined to the distal cartilaginous portion at the iliac side.”

    • Dr. McGrath, thanks so much for your addition to the discussion and insight! If you are ever interested in contributing a guest article on this topic, I am sure my readers would love for you to elaborate, I know I would! Thanks again,
      Mike

  23. Great comments on SIJ testing. I like the use of latest and relevent research and the Videos were really helpful.
    Thanks for all the help.

  24. Mulugeta Bayisa Reply May 2, 2013 at 4:37 am

    I am really impressed with the presentation. It helps as a quick reference for physiotherapists.
    Keep it up!

  25. Im in 4th year of Physical therapy.we get a better stuff from here rather then exploring our course books where the information is not so interesting.This kind of knowledge is so helpful..thankyou for sharing it!!!

  26. Great summary, Mike. Thank you for sharing. I tend to utilize the tests described by Laslett, as opposed to testing for positional fault, asymmetry, etc… Have you seen this study by Tulberg?http://journals.lww.com/spinejournal/Abstract/1998/05150/Manipulation_Does_Not_Alter_the_Position_of_the.10.aspx

    It not only demonstrates again the poor reliability of such tests, but also goes a step further in showing that we are unable to correct these “malalignments” even if they do exist – even though the positional tests after manual treatment were judged to demonstrate a “correction”. Nevertheless, PTs for years have gotten good results from such a treatment approach. My suspicion is that the success is due to some other mechanism(s) – rather than correction of asymmetry. However, I still feel people should take caution in using that approach – so as not to create a fear of movement and subsequent fear avoidance beliefs. I’ve encountered this in patients who had previously been treated with the misalignment approach. They were very cautious with movement and activities in general for fear of moving something out of place. Convincing them otherwise can be very difficult. Daniel

  27. How come I ended up with a physical therapist who had zero understanding of chronic pain? My SIJ pain has taken away my ability to sit, stand and walk. How would you like to spend your life horizontal? After spine surgery x3 (1 anterior/3 level and 1 posterior fusion), she thought if my hips were level, then I must be lying if I c/o SIJ pain. After her crazy course of P.T. I ended up bedridden 95% of the time for the last 7 years.

    As a former ICU R.N., I am completely frustrated with the amount of severe pain I live with on a daily basis. I cannot believe I can’t get some help. As a former gymnast and distance runner, I can easily live with some pain and dislike being sedentary.

    If you want to chalk me up as a baby of a patient, let me say I have fractured an ankle (needing surgical intervention) and a foot and barely noticed the discomfort. I forgo novacaine on dental visits for cavities.

    I have been in pain for 25 years. I do not want to live out my final years continuing to go downhill. Does anyone have any real suggestions? Is there anything new out there or on the horizon? I could use a hero to step up and help me today. I got in this mess because I was helping a patient in need and now I am the one in need.

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Trackbacks/Pingbacks

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  3. And I thought SIJ movement tests were not taught anymore? | In Touch Physical Therapy Blog - December 9, 2013

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