Special Tests: Sacroiliac Joint (SIJ)

by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, how we chose the tests in these lessons, and best use, check out:

Special Tests Covered in this Lesson:

Special Note on SIJ Special Tests:

Most palpation, motion and position assessments for the sacroiliac joint (SIJ) have questionable reliability. However, research has demonstrated the reliability and accuracy of the Laslett's Cluster II: Sacroiliac Joint Pain Test-item Cluster, which has been used as the outline for much of this course (4, 5, 22, 23). It is worth noting that SIJ pain provocation tests are more specific than sensitive (4 - 21). This implies that a positive result carries more weight then a negative result.  More research is needed to find sensitive screening tools for SIJ dysfunction.

A review of relevant SIJ assessment research is also covered in this course, with the intent of suggesting a possible cluster for assessing altered motion. While the Laslett's Cluster II is accurate and reliable, it is a pain provocation cluster that does not aid in determining which side should be mobilized, manipulated or stabilized. The Gillet Test, which is included in the Brookbush Insitute's (BI) recommended cluster, is a motion Test that has demonstrated good reliability (24). Further, research suggests that including a reliable assessment in a cluster of reliable assessments is likely to increase accuracy. The BI recommended cluster is loosely based on the Grieve et. al cluster (70), which demonstrated good reliability and accuracy in an observational study. Note, further research is needed on SIJ movement clusters and the specific cluster in recommended this course; however, until that research is performed a reasonable cluster is needed to aid in refining intervention selection in practice.

Sacral Thrust, Compression, and Distraction

Sacral Thrust:

  1. The patient lies in a prone position, and is asked about current symptoms.
  2. The examiner then palpates the midpoint of the sacrum by "falling off" the posterior superior iliac spine (PSIS) medially.
  3. The pisiform portion of the hand/wrist is placed on the middle of the sacrum or sacral base as if performing a posterior to anterior sacroiliac joint mobilization. Applying the force to the level of the 3rd sacral spinous process (middle of sacrum) will reduce the likelihood of pushing the lumbar spine into extension.
  4. Vigorous and repeated thrusts (up to 6 thrusts) in a downward direction are performed in an attempt to reproduce the concordant sign.

    • Note: The Brookbush Institute recommends starting with a slow but forceful push to the end of passive accessory motion, prior to thrusting.  If a slow build-up of pressure reproduces the concordant sign or symptoms, thrusts are likely unnecessary.
  5. It the test reproduces the concordant sign the test is positive.

Test for:Sacroiliac Joint Pain
Action:Posterior to anterior thrust of the sacrum on the ilium
Statistics:Likely more specific than sensitive (1, 4-7). It is important to apply force to the middle of the sacrum and reduce the amount of lumbar extension.  An increase in lumbar extension would artificially reduce specificity by potentially including lumbar spine issues.
Best use:Sign in Cluster: This test is not particularly reliable or sensitive (4 - 7), and should likely be used only in conjunction with other tests.
Included in Clusters:Laslett's Cluster II

Compression Test:

  1. The patient assumes a side-lying position with painful side up, and is asked about current symptoms.
  2. The examiner then cups the top side iliac crest with both hands to reduce help spread force over a larger surface area
  3. A downward force is applied on the ilium. It is likely that the practitioner will need to lay their torso on top of their hands to apply sufficient pressure.
  4. This position is held for 30 seconds. Due to the sensitivity issues with this test, it may be advisable to additionally test tolerance of several downward thrusts if sustained pressure was tolerated without provocation of symptoms.
  5. It the test reproduces the concordant sign the test is positive.

Test for:Sacroiliac joint pain (1-13), and potentially pelvic fracture (14)
Action:Compression of ilium and sacrum in side-lying.
Statistics:Good specificity, but low sensitivity (4-8, 12, 14)
Best use:Sign in Cluster: This test is not sensitive enough to be used as screen, and should likely be used only in conjunction with other tests (1, 4-8, 12, 14).
Included in Clusters:Laslett's Cluster II

Distraction Test (Anterior Sacroiliac Joint Stress Test):

  1. The patient assumes a supine position, and is asked about current symptoms.
  2. The examiner palpates the medial side of both anterior superior iliac spine (ASIS).
  3. The examiner crosses their arms, resulting in "X" shape, and places each hand on the patient's opposing ASIS. The examiner should use as much of the softest part of the palm as possible to push on the ASIS, reducing point pressure discomfort. The examiner may have to adjust hand position several times.
  4. The examiner then applies a downward (spreading the anterior sacroiliac joing) force for 30 seconds. Due to the sensitivity issues with this test, it may be advisable to additionally test tolerance of several downward thrusts if sustained pressure was tolerated without provocation of symptoms.
  5. It the test reproduces the concordant sign the test is positive.

Test for:Sacroiliac joint pain (1-9, 11-14)
Action:Lateral pressure on ASIS, spreading the anterior sacroiliac joints
Statistics:Good reliability and specificity, low sensitivity (1-4, 6 - 8, 12-14)
Best use:Sign in Cluster: Although, this is one of the better sacroiliac joint pain provocation tests, it still does not appear to be strong enough to be used alone. It is the only test performed with the intent to assess integrity of the anterior sacroiliac joint ligaments.
Included in Clusters:Laslett's Cluster II

Thigh Thrust:

Note: This test should only be performed if the patient is free of hip pathology/pain

  1. The patient assumes a supine position, and is asked about current symptoms.
  2. The examiner stands opposite the painful side of the patient.
  3. The hip on the painful side is flexed to 90 degrees, and the examiner uses the hand closes to the patients head to pull the leg and tip the patients hips and pelvis closer to them.
  4. The examiner then slides their other hand under the sacrum, so the palm is firmly cupping the majority of the sacrum.
  5. The patient is then tilted back over the examiners hands, so the examiners hand is now creating a stable platform for the sacrum to sit on.
  6. The examiner then uses the thigh of the painful side to apply a vigorous downward force in an attempt to shear the ilium.
  7. It the test reproduces the concordant sign near the sacroiliac joint on the tested side, the test is positive.

Test for:Sacroiliac Joint Pain (1-7, 9-12, 15 - 21)
Action:Shearing force, iliac on sacrum
Statistics:Fair reliability, more specific than sensitive; however, this test has the highest sensitivity of those included in this course (1-7, 9-12, 15 - 21)
Best use:Sign in Cluster - Although this test is strong alone, sensitivity and specificity are better when performed in a cluster.
Included in Clusters:Laslett's Cluster II

 

Gaenslen's Test

  1. The patient assumes "Thomas Test Position" - A supine position at the end of a table with one leg clutched to chest, and the other hanging.

    • The easiest method to get a patient in this position is to have the patient stand at the end of table, cue them to sit their sacrum on the edge of the table, ask them to clutch the leg you wish to have at their chest in this sitting position, and then assist them as they roll back into supine with the leg still clutched.
  2. Ask the patient about current symptoms.
  3. The examiner then places a hand near the knee of the "up" leg, and on the thigh of the "down" leg with the intent of applying downward force to both legs. The test intends to push the "up" leg further into flexion, and the "down" leg further into extension, resulting in nutation and counter-nutation forces on the SIJs.
  4. Once the examiner is comfortable, and in position to apply these forces, up to 6 thrusts are performed while asking the patient about their current symptoms.
  5. It the test reproduces the concordant sign near the sacroiliac joint or pubis the test is positive.

    • Both sides/positions (right leg up, or left leg up) may result in positive test results for either SIJ.

Test for:Sacroiliac joint pathology (1-5, 7, 9, 18)
Action:Counter-nutation of the SIJ on "leg down" side, and potentially nutation on the "leg up" side.
Statistics:This test is more specific than sensitive, but even specificity is poor (4, 5, 7, 9, 18).
Best use:Sign in Cluster - This test should not be used alone. It is only included due to the tests inclusion in a test-item cluster.
Included in Clusters:Laslett's Cluster II

Laslett's Cluster II: Sacroiliac Joint Pain Test-item Cluster

Test for:Sacroiliac Joint Pain (22)
Action:Laslett's Cluster II: Sacroiliac Joint Pain Test-item Cluster
Statistics:Three out of five positive tests results in 91% sensitivity and 87% specificity for sacroiliac joint related pain. The practitioner may consider starting with the Sacral Thrust Test and Distraction Tests as a prior study demonstrated positive test results for both had 88% sensitivity and 78% specificity (4).
Best use:Performing Obrien's Active Compression Test first represents the use of this test as a "pivot" from the Instability/Labrum Composite Test-item Cluster.

Additional Pain Provocation Tests (not included on test):

Van der Wurff et al. Pain Provocation Test-item Cluster (23) (not included on test)

Sacroiliac Joint Motion (SIJ) Exam

Stork Test (a.k.a. Gillet's Test or One-legged Stand Test)

  1. The patient starts in a standing position with feet shoulder width apart.
  2. The clinician places one finger on the PSIS, and one finger on the sacrum close to it.

    • Various texts suggest different landmarks on the sacrum including the sacral base, S2 spinous process and inferior lateral angle (ILA). It is likely more important to be consistent with your palpation.
  3. The examiner then asks the patient to flex the hip on the side being palpated, knee to hip height, like a high march.
  4. The examiner monitors motion of the PSIS relative to the sacrum.
  5. The same is then done on the other side.
  6. Ideally, the pelvis as a whole would not tilt anterior or lateral, and no rotation would occur.  Normal pelvic motion during marching may include a small amount of posterior tilting on the side of hip flexion relative to a stationary sacrum.
  7. A positive test for SIJ stiffness is elevation, no motion, or less motion than the opposite side.

Test for:SIJ Stiffness (1-3, 24)
Action:Examination of SIJ motion during marching.
Statistics:The reliability of this test is good; however, there is no validity data currently (1-3, 23).
Best use:

The Brookbush Institute recommends using the Gillet Test as part of a cluster to determine the presence of asymmetrical stiffness, with the intent of informing best-practice. (See Appendix below for more information)

Brookbush/Grieve Cluster

Assess:

Treat:

 

Appendix: Research Review for the Development of a Movement Cluster

Summary

Focus should be placed on addressing stiffness and asymmetry and not sacral position and range of motion.

  • SIJ injection provides strong evidence that SIJ dysfunction is contributes significantly to 15 – 30% of low back pain cases.
  • The SIJ are capable of approximately 1.6 - 6° or rotation, and 0.1 - 2.0 mm of translation.
  • It may be reasonable to conclude that SIJ motion is as difficult to palpate as lumbar facet motion; however, well within the limits of fingertip sensitivity.
  • Asymmetrical stiffness likely alters motion and results in dysfunction and pain; it is unlikely that dysfunction is the result of a change in total ROM.
  • Imaging may be specific but not sensitive, subjective examination lacks reliability, and palpation of sacral position lacks reliability and accuracy.
  • Clustering pain provocation exams increases reliability and accuracy, as demonstrated by the Laslett Cluster II 
  • The Gillet Test is reliable when constrained to 2 or 3 possible outcomes (More stiff on right, More stiff on left, Even)
  • Grieve et al. demonstrated accuracy and reliability when the Gillet Test was combined with hip ROM asymmetry and palpation of the superior ligament of the symphysis pubis.
  • Manipulation results in improved SIJ symmetry, hip ROM symmetry, gait symmetry, pain and disability.

Does Sacroiliac Joint (SIJ) Dysfunction contribute to Low Back Pain

Sacroiliac joint (SIJ) manipulation is a controversial topic, primarily due to false notions regarding SIJ motion and SIJ assessment. Several studies have used injection to demonstrate that SIJ dysfunction contributes to low back pain. In a study by Fortin et al. on asymptomatic individuals, injection into the SIJ immediately revealed an area of buttock hyperesthesia extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine (Fortin area) (25). In a follow-up study, 16 patients were selected whose pain most closely matched the "Fortin area", of these patients 10 benefited from therapeutic injection (26). Van der Wurff et al. mapped the area and intensity of chronic low back pain patients, and then compared responder and non-responders to double diagnostic SIJ injection. The findings suggest that there were no significant differences in area; however, the intensity of specific areas did differ; with 100% of SIJ injection responders exhibiting more intense pain in the "Fortin area" and only 10% of SIJ injection responders with more intense pain at the ischial tuberosity (27). Maigne et al. demonstrated that nearly 20% of individuals with low back pain and diagnosed SIJ dysfunction, experienced at least temporary relief from fluoroscopic guided SIJ anesthetic block (28). Slipman et al. demonstrated that flouroscopic guided injections effectively reduced pain, disability and increased time at work during a 2 year follow-up of patients diagnosed with SIJ dysfunction (29). Soneji et al. demonstrated no significant difference between ultrasound guided and flouroscopy guided SIJ injections, with both resulting in significant reduction from baseline mean pain scores, as well as improvements in physical functioning, discomfort, opioid utilization, and patient satisfaction (30). Although more research is needed to aid in refining assessment and injection interventions, the effect of SIJ injection on low back pain provides strong evidence that SIJ dysfunction is a significant contributor to low back pain.

SIJ Motion

Several exacting methods of motion analysis have been used to determine the amount of motion of the SIJ. In studies by Jacob et al. and Kissling et al., using a three-dimensional stereophotogrammetric method with intraosseous markers, transition from sitting to standing resulted in average values for rotation and translation of 1.8°/0.7 mm for males and 1.9°/0.9 mm for the females. Based on a couple of individual cases in the study, it was postulated that pathological sacroiliac joint instability may occur when values are more than 6.0°/2 mm (31, 32). Egund et al. used roentgen stereophotogrammetry to demonstrate that during bilateral motions, the sacrum moved primarily around a transverse axis about 2°, and the distance between the two superior posterior iliac spines varied at most by 0.4 mm during 7 different body positions (33). In a study by Wilke et al., Schanz screws were implanted in S1 and the ilium and measured continuously with a three-dimensional goniometric system. The maximum rotation angle in the sagittal plane was 1.3° on the right and 1.6° on the left for flexion plus extension. Extension of the hip always produced the largest motion in the sacroiliac joint (34). Cibulka et al. also demonstrated small reciprocal motions in straddle position using radiostereometric analysis that matched the amount of motion demonstrated in other studies (35). Additionally, two studies by Struesson et al. demonstrated that movement of the sacroiliac joint was small during the standing hip flexion test when compared to reciprocal straddle position, suggesting that standing may reduce SIJ motion due to muscular contraction or form closure (36, 37). These studies indicate that the SIJ are capable of approximately 1.6 - 6° or rotation, and/or 0.1 - 2.0 mm of translation. Although, the initial impression of these motions may result in jumping to a conclusion that they are small and insignificant, we must be careful not to impose a subjective value without reference.

How much is 2 to 3mm?

It is easy to see 1.6 - 6° or rotation, or translation of 0.1 - 2.0 mm and think that motion of the SIJ is not worth consideration; however, these motions should be considered relative to other joint motions. Kozanek et al. demonstrated that during flexion-extension movements of the trunk, the lumbar facets rotated primarily along a mediolateral axis an average of 2°–6°, and translated (glide) in a cranial/caudal direction an average 2–4 mm (38). There are very few practitioners who would argue that motion of the lumbar facets are not palpable, and yet, the amount of motion is similar to the motion reported by studies on the SIJ. The next reasonable question to ask may be: "How sensitive are the receptors in the fingertips, and what is the threshold amount of motion that can be reliably palpated?". A reasonable conclusion about fingertip sensitivity may be made by analogy, comparing the amount of SIJ motion to studies on the height of braille letters and reading speed/comprehension by the blind. Lei et al. demonstrated that when blind adults were tested with the lowest braille heights (0.04mm), more repeated motions over words and slower reading speeds occurred; however, repeated movements and reading speed were normal at medium and high braille heights (o.18 and 0.38mm) (39). This implies that it is possible to comfortably identify the difference in braille letters when heights are 1/5 of a mm, and reading could still take place at 1/20th of a mm. These heights are between 10 and 50 times smaller than the amount of motion of the SIJ. Although palpation and assessment of SIJ motion may be more difficult than palpating glide at the shoulder or hip, it may be reasonable to conclude that SIJ motion is as difficult to palpate as lumbar facet motion, and well within the limits of fingertip sensitivity.

SIJ Dysfunction and Altered Motion

Additional motion studies have investigated how SIJ motion is altered by pain and dysfunction. Kibsgård et al. demonstrated that the straight let raise test resulted in 0.8° of posterior rotation and and 0.3° inward tilt of the straight leg ilium on the sacrum in patients with long-standing severe sacroiliac joint pain (40). Sturesson et al. used roentgen stereophotogrammetry to investigate SIJ motion in 25 patients with SIJ disorders, in various normal and extreme physiologic positions, demonstrating a mean ROM of 2.5° (0.8 degree-3.9 degrees), and mean translation of 0.7 mm (0.1-1.6 mm). There was no difference between symptomatic and asymptomatic joints (41). Adhia et al. demonstrated that when SIJ-negative low back pain patients were compared to SIJ-positive low back pain patients (diagnosed using test cluster), they exhibited significantly different innominate movement patterns and trends of rotation, but not innominate ranges of motion (42). Buyruk et al. demonstrated a correlation between asymmetric stiffness and pelvic pain using a novel Doppler imaging of vibration technique (43). In another study by the same group, Damen et al. demonstrated that using the vibration imaging technique to assess SIJ asymmetric laxity had a sensitivity of 65%,, specificity of 83%, and positive predictive value 77% for pregnancy-related pelvic pain persisting postpartum (44). The studies by Adhia et al., Buyruk et al. and  Damen et al. may suggest that asymmetric stiffness is the physical phenomena leading to changes in motion and pain, and not changes in total ROM (42, 43, 44). Adding to the "asymmetry hypothesis", Cibulka et al. demonstrated that patients with low back pain without evidence of SIJ dysfunction had more hip external ROM than internal ROM bilaterally, whereas those with evidence of SIJ dysfunction had significantly more hip external ROM than internal ROM unilaterally, specifically on the side of the posterior innominate (45). These studies imply that determining how dysfunction effects total SIJ ROM may be the wrong hypothesis to investigate. Instead, these studies suggest that asymmetric stiffness likely alters motion during activity and is correlated with dysfunction and pain. The change in stiffness without a change in total ROM may be similar to the changes described in the Panjabi et al.'s neutral zone hypothesis for the lumbar spine (46, 47). The application of this model to both the lumbar spine and SIJ also increases congruence between hypothesized spine dysfunction, suggesting that changes in motion of various segments of the spine may occur do to similar mechanisms.

Changes in Motion Following Manipulation

Studies have demonstrated some changes in pelvic motion and position post manipulation; however, based on research findings expectations should be modified. Tullberg et al. compared roentgen stereophotogrammetric analysis and position tests before and after manipulation in 12 individuals with unilateral sacroiliac joint dysfunction, demonstrating that manipulation did not change the position of the sacrum in standing; however, manual sacral position tests did change from positive to normal (48). This may suggest that the effects of manipulation do not alter sacral position and that manual sacral position tests are not valid; however, these tests may still have diagnostic benefit if capable of identifying individuals who would benefit from sacral directed therapies. In an RCT by Cibulka et al., 20 patients who had sided low back pain and SIJ dysfunction were randomly assigned to control and experimental groups and pelvic tilt was measured. The experimental group was manipulated on the side of stiffness resulting in equal and opposing tilting toward normalization of both innominates during retesting (based on relative ASIS and PSIS height) (49). This may imply that while sacral position is not palpable, inomminate tilt may be palpable and used as a reliable assessment of manipulation success. In a quasi-experimental study by de Toledo et al. manipulation did not result in significant changes in SIJ mobility; however, the clear trend in the data may also suggest that this study was too small to reach statistical significance (50). Conversely Mahmoud et al. demonstrated that posterior iliosacral joint manipulation increased SIJ ROM, reduced hyperlordosis of the lumbar spine, and decreased SIJ and low back pain (51). Based on these research studies, and the studies discussed below regarding treatment, manipulation should be expected to alter iliac position and not sacral position, improve asymmetry but potentially not SIJ mobility, and reduce symptoms associated with SIJ dysfunction.

Testing

Several studies have investigated the accuracy of imaging and medical examination for the diagnosis of SIJ dysfunction. Elegafy et al. demonstrated that computed tomography had a sensitivity of 57.5% and a specificity of 69%, based on a comparison to the number of patients who tested positive using SIJ Injection (anesthetic block) (52). Slipman et al. demonstrated that of 31 patients, 19 responded to SIJ block, only 4 responders had signs of SIJ dysfunction on bone scans, and zero non-responders had signs on bone scans (53). These studies may suggest that imaging has high specificity, but very low sensitivity. Additional studies using radiographs imply a correlation between SIJ dysfunction and femoral acetabular impingement syndrome (FAI). Krishnamoorthy et al. demonstrated a high percentage of SIJ abnormalities on radiographs (25.2%) in patients with FAI (54). Further, Morgan et al. demonstrated the a significant number of patients meeting a strict criteria for SIJ pain had radiographic evidence of FAI or hip arthrosis (55). Arthography may demonstrate some of the physical phenomena that may be contributing to SIJ pain. Fortin et al. demonstrated the extravasation of contrast medium during arthrogram of the SIJ, which may imply micro-damage of SIJ capsular structures and/or the potential of intra-articular fluids to aggravate adjacent neural structures (56). Schwarzer et al. demonstrated similar findings; of 13 low back pain patients (30%) who obtained relief from an anesthetic SIJ block, 9 exhibited tears of the anterior capsule during arthrography (57). Dreyfuss et al. demonstrated that the combination of medical history and physical examination was also not particularly beneficial for assessing the contribution of SIJ dysfunction to low back pain (58). And, Freburger et al. demonstrated that using calipers and inclinometers for determining SIJ motion and dysfunction was unreliable in a multicenter study (59). These studies demonstrated that imaging may be specific but lacks sensitivity, that medical examination alone lacks reliability, there appears to be a correlation between SIJ dysfunction and FAI, and arthography may be useful in aiding in further research.

Studies have demonstrated reliable diagnosis of SIJ pain using clusters of the most effective SIJ special tests for pain provocation. A study by Laslett et al. in 1994 demonstrated that many of the pain provocation tests were reliable (60). In 2003 and 2005, Laslett et al. reported the accuracy of a test cluster resulted in 94% sensitivity and 78% specificity, using anesthetic SIJ block as the comparison criteria (61, 62). Further, in 2009, a meta-analysis by Szadek et al. demonstrated that the thigh thrust test, the compression test, and 3 or more positive stressing tests (as used in the Laslett Cluster) demonstrated discriminating power for diagnosing SIJ pain (63). The Laslett Cluster is covered in detail in the course, "Special Tests: Sacroiliac Joint". The success of the pain provocation cluster may imply that clustering exams is a potential path to reliable movement assessment. An interesting comparison by Soleimanifer et al. demonstrated that there was no correlation between findings of SIJ motion special tests, and SIJ pain provocation special tests. It is important to note that most or the tests used were not part of any cluster currently supported by research (Sitting flexion, Standing flexion, Prone knee flexion, Gillet test, FABER, Posterior shear, Resisted abduction test) (64). However, the idea that a reliable pain cluster and a reliable movement cluster should demonstrate correlation is likely an important goal in the development of a movement cluster. These studies demonstrate that there is a reliable approach for diagnosing SIJ pain, and that clustering exams may be a viable option for improving SIJ movement assessment accuracy.

Several studies have investigated the accuracy of movement assessments. Herzog et al. demonstrated that some palpation procedures demonstrated reliability, but not others; which implies that more reliable training protocols should be developed to teach motion palpation (65). Lueck et al demonstrated inter- and intra-rater reliability at a single clinic was variable for SIJ motion exams, noting that intra-rater reliability was higher than inter-rater reliability, and that it was the amount of daily practice and not years of experience that effected reliability (66). Hungerford et al. demonstrated that the reliability of the Gillet Test was high when findings were reduced to a 2-point scale (PSIS remained neutral or moved cranially), and were still moderate when a 3-point scale was used (PSIS neutral, cranial or anterior) (67). Levangie et al. demonstrated that a positive Gillet Test had a relatively high specificity for low back pain (presumably related to SIJ hypomobility), but only weak association with PSIS height, and no correlation with standing forward flexion Test, sitting forward flexion Test, or supine-to-sit Test (68) Interestingly, Cibulka et al. demonstrated 82% sensitivity, 88% for specificity, 86% positive predictive and 84% for negative predictive value for a combination of many of the same tests mentioned above, including the standing flexion text, sitting posteior-superior iliac spine palpation, supine long-sitting Test, prone knee flexion Test (69). Considering the relatively high reliability of the Gillet Test and the relatively high accuracy of the tests investigated by Cibulka et al., it seems likely that these assessments are testing different phenomenon correlated with SIJ dysfunction. An interesting study by Grieve et al. should have inspired further research. Grieve et al. demonstrated that a test cluster including the Gillet Test revised by the author (alternate hip and knee flexion in supported standing), passive hip rotation RO in supine with 90° of hip and knee flexion, and palpation of the superior ligament of the symphysis pubis were reliable for identifying individuals referred by a physician who responded to SIJ manipulation in conjunction with education on living modification and a progressive walking program (70). What is interesting about this cluster is the use of the most reliable movement Test, a focus on identifying asymmetry, pain with palpation which research has demonstrated has high specificity for other joints, and correlation with the success of the implied treatment. These concepts and many of the same assessments were used in the cluster recommended below. These studies suggest that most SIJ movement assessments are likely unreliable and inaccurate alone; however, a cluster of assessments may be more reliable and accurate. The Gillet Test when constrained to 2 or 3 possible outcomes is likely the most reliable individual assessment. Further, based on the studies above, it may be reasonable to conclude that a movement cluster should focus s on identifying asymmetrical stiffness and asymmetrical motion, with the intent of predicting best practice for improving stiffness and asymmetry.

Brookbush/Grieve (70) Recommended Cluster:

Assess:

Treat:

 

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  19. Gutke, A., Hansson, E. R., Zetherström, G., & Östgaard, H. C. (2009). Posterior pelvic pain provocation test is negative in patients with lumbar herniated discs. European spine journal18(7), 1008-1012.
  20. Ostgaard, H. C., & Andersson, G. B. (1991). Previous back pain and risk of developing back pain in a future pregnancy. Spine16(4), 432-436.
  21. Bogduk, N. (1999). Pain provocation tests for the assessment of sacroiliac joint dysfunction. Clinical Spine Surgery12(4), 357.

    • Gaenslen's Test (1-5, 7, 9, 18)
    • Laslett's Cluster II
  22. Laslett, M., Young, S. B., Aprill, C. N., & McDonald, B. (2003). Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy49(2), 89-97.
  23. van der Wurff, P., Buijs, E. J., & Groen, G. J. (2006). A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Archives of physical medicine and rehabilitation87(1), 10-14.

    • Stork Test
  24. Hungerford, B. A., Gilleard, W., Moran, M., & Emmerson, C. (2007). Evaluation of the ability of physical therapists to palpate intrapelvic motion with the Stork test on the support side. Physical Therapy87(7), 879-887.

    • Injection demonstrates contribution of SIJ to low back pain
  25. Fortin, J. D., Dwyer, A. P., West, S., & Pier, J. (1994). Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part I: Asymptomatic volunteers. Spine19(13), 1475-1482.
  26. Fortin, J. D., Aprill, C. N., Ponthieux, B., & Pier, J. (1994). Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical evaluationSpine19(13), 1483-1489.
  27. van der Wurff, P., Buijs, E. J., & Groen, G. J. (2006). Intensity mapping of pain referral areas in sacroiliac joint pain patients. Journal of manipulative and physiological therapeutics29(3), 190-195.
  28. Maigne, J. Y., Aivaliklis, A., & Pfefer, F. (1996). Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine21(16), 1889-1892.
  29. Slipman, C. W., Lipetz, J. S., Plastaras, C. T., Jackson, H. B., Vresilovic, E. J., Lenrow, D. A., & Braverman, D. L. (2001). Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome. American journal of physical medicine & rehabilitation80(6), 425-432.
  30. Soneji, N., Bhatia, A., Seib, R., Tumber, P., Dissanayake, M., & Peng, P. W. (2016). Comparison of fluoroscopy and ultrasound guidance for sacroiliac joint injection in patients with chronic low back pain. Pain Practice16(5), 537-544.

    • Sacroiliac Joint Motion
  31. Jacob, H. A. C., & Kissling, R. O. (1995). The mobility of the sacroiliac joints in healthy volunteers between 20 and 50 years of age. Clinical Biomechanics10(7), 352-361.
  32. Kissling, R. O., & Jacob, H. A. (1996). The mobility of the sacroiliac joint in healthy subjects. Bulletin (Hospital for Joint Diseases (New York, NY))54(3), 158-164.
  33. Egund, N., Olsson, T. H., Schmid, H., & Selvik, G. (1978). Movements in the sacroiliac joints demonstrated with roentgen stereophotogrammetry. Acta Radiologica. Diagnosis19(5), 833-846.
  34. Wilke, H. J., Fischer, K., Jeanneret, B., Claes, L., & Magerl, F. (1997). In vivo measurement of 3-dimensional movement of the iliosacral joint. Zeitschrift fur Orthopadie und ihre Grenzgebiete135(6), 550-556.
  35. Cibulka, M. T. (2001). Re: a radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. Spine26(12), 1404-1405.
  36. Sturesson, B., Uden, A., & Vleeming, A. (2000). A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion testSpine25(3), 364-368.
  37. Sturesson, B., Uden, A., & Vleeming, A. (2000). A radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. Spine25(2), 214.

    • Comparison
  38. Kozanek, M., Wang, S., Passias, P. G., Xia, Q., Li, G., Bono, C. M., ... & Li, G. (2009). Range of motion and orientation of the lumbar facet joints in vivo. Spine34(19), E689-E696.
  39. Lei, D., Stepien-Bernabe, N. N., Morash, V. S., & MacKeben, M. (2019). Effect of modulating braille dot height on reading regressionsPloS one14(4), e0214799.

    • Motion and Dysfunction
  40. Kibsgård, T. J., Röhrl, S. M., Røise, O., Sturesson, B., & Stuge, B. (2017). Movement of the sacroiliac joint during the Active Straight Leg Raise test in patients with long-lasting severe sacroiliac joint pain. Clinical Biomechanics47, 40-45.
  41. Sturesson, B. E. N. G. T., Selvik, G., & UdÉn, A. (1989). Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine14(2), 162-165.
  42. Adhia, D. B., Milosavljevic, S., Tumilty, S., & Bussey, M. D. (2016). Innominate movement patterns, rotation trends and range of motion in individuals with low back pain of sacroiliac joint origin. Manual therapy21, 100-108.
  43. Buyruk, H. M., Stam, H. J., Snijders, C. J., Laméris, J. S., Holland, W. P., & Stijnen, T. H. (1999). Measurement of sacroiliac joint stiffness in peripartum pelvic pain patients with Doppler imaging of vibrations (DIV). European Journal of Obstetrics and Gynecology and Reproductive Biology83(2), 159-163.
  44. Damen, L., Buyruk, H. M., Güler-Uysal, F., Lotgering, F. K., Snijders, C. J., & Stam, H. J. (2002). The prognostic value of asymmetric laxity of the sacroiliac joints in pregnancy-related pelvic pain. Spine27(24), 2820-2824.
  45. Cibulka, M. T., Sinacore, D. R., Cromer, G. S., & Delitto, A. (1998). Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine, 23(9), 1009-1015.
  46. Panjabi, M. M. (1992). The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. Journal of spinal disorders5(4), 383-9.
  47. Panjabi, M. M. (1992). The stabilizing system of the spine. Part II. Neutral zone and instability hypothesisJournal of spinal disorders5, 390-390.

    • Changes in Motion Following Manipulation:
  48. Tullberg, T., Blomberg, S., Branth, B., & Johnsson, R. (1998). Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine23(10), 1124-1128.
  49. Cibulka, M. T., Delitto, A., & Koldehoff, R. M. (1988). Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain: an experimental study. Physical Therapy68(9), 1359-1363.
  50. de Toledo, D. D. F. A., Kochem, F. B., & Silva, J. G. (2019). High-velocity, low-amplitude manipulation (HVLA) does not alter three-dimensional position of sacroiliac joint in healthy men: A quasi-experimental studyJournal of Bodywork and Movement Therapies.
  51. Mahmoud, Y. M., Kattabel, O. M. A., & Amin, D. I. (2016). Effect of Posterior Iliosacral Joint Manipulation on Subjects With Hyperlordosis of Lumbar Spine. Isotope and Radiation Research48(1), 87-95.

    • Testing
  52. Elgafy, H., Semaan, H. B., Ebraheim, N. A., & Coombs, R. J. (2001). Computed tomography findings in patients with sacroiliac pain. Clinical orthopaedics and related research382, 112-118.
  53. Slipman, C. W., Sterenfeld, E. B., Chou, L. H., Herzog, R., & Vresilovic, E. (1996). The value of radionuclide imaging in the diagnosis of sacroiliac joint syndrome. Spine21(19), 2251-2254.
  54. Krishnamoorthy, V. P., Beck, E. C., Kunze, K. N., Cancienne, J. M., Krivicich, L. M., Suppauksorn, S., ... & Nho, S. J. (2019). Radiographic Prevalence of Sacroiliac Joint Abnormalities and Clinical Outcomes in Patients With Femoroacetabular Impingement Syndrome. Arthroscopy: The Journal of Arthroscopic & Related Surgery35(9), 2598-2605.
  55. Morgan, P. M., Anderson, A. W., & Swiontkowski, M. F. (2013). Symptomatic sacroiliac joint disease and radiographic evidence of femoroacetabular impingement. Hip International23(2), 212-217.
  56. Fortin, J. D., Vilensky, J. A., & Merkel, G. J. (2003). Can the sacroiliac joint cause sciatica?. Pain physician6(3), 269-272.
  57. Schwarzer, A. C., Aprill, C. N., & Bogduk, N. (1995). The sacroiliac joint in chronic low back pain. Spine20(1), 31-37.
  58. Dreyfuss, P., Michaelsen, M., Pauza, K., McLarty, J., & Bogduk, N. (1996). The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine21(22), 2594-2602.
  59. Freburger, J. K., & Riddle, D. L. (1999). Measurement of sacroiliac joint dysfunction: a multicenter intertester reliability study. Physical therapy79(12), 1134-1141.
  60. Laslett, M., & Williams, M. (1994). The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine19(11), 1243-1249.
  61. Laslett, M., Young, S. B., Aprill, C. N., & McDonald, B. (2003). Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy49(2), 89-97.
  62. Laslett, M., Aprill, C. N., McDonald, B., & Young, S. B. (2005). Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual therapy10(3), 207-218.
  63. Szadek, K. M., van der Wurff, P., van Tulder, M. W., Zuurmond, W. W., & Perez, R. S. (2009). Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. The Journal of pain10(4), 354-368.
  64. Soleimanifar, M., Karimi, N., & Arab, A. M. (2017). Association between composites of selected motion palpation and pain provocation tests for sacroiliac joint disorders. Journal of bodywork and movement therapies21(2), 240-245.
  65. Herzog, W., Read, L. J., Conway, P. J., Shaw, L. D., & McEwen, M. C. (1989). Reliability of motion palpation procedures to detect sacroiliac joint fixations. Journal of manipulative and physiological therapeutics12(2), 86-92.
  66. Lueck, D. (2009). Reliability of sacroiliac joint tests in experienced and inexperienced examiners.
  67. Hungerford, B. A., Gilleard, W., Moran, M., & Emmerson, C. (2007). Evaluation of the ability of physical therapists to palpate intrapelvic motion with the Stork test on the support side. Physical Therapy87(7), 879-887.
  68. Levangie, P. K. (1999). Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Physical Therapy79(11), 1043-1057.
  69. Cibulka, M. T., & Koldehoff, R. (1999). Clinical usefulness of a cluster of sacroiliac joint tests in patients with and without low back pain. Journal of Orthopaedic & Sports Physical Therapy29(2), 83-92.
  70. Grieve, E. (2001). Diagnostic tests for mechanical dysfunction of the sacroiliac joints. Journal of Manual & Manipulative Therapy9(4), 198-206.

 

© 2019 Brent Brookbush

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