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Friday, December 29, 2023

Myths About Sacroiliac Joint (SIJ) Motion, Palpation, Assessment, and Treatment

Myths About Sacroiliac Joint (SIJ) Motion, Palpation, Assessment, and Treatment
Brent Brookbush

Brent Brookbush

DPT, PT, MS, CPT, HMS, IMT

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Much of this article is cited from the course:

Introduction

There is a significant amount of misinformation about the sacroiliac joint (SIJ) circulating on blogs and social media. Most of the misinformation suggests we should not worry about the SIJ because it does not move much, cannot be reliably palpated; and therefore, cannot be reliably assessed or effectively treated. However, these are just more examples of unscientific thinking, poor scholarship (e.g. failure to review the available research), and excuse-driven therapy.

  • Excuse-driven Therapists are Nihilistic professionals creating post hoc arbitrary quality standards, to aid in dismissing research, assessments, or interventions that they do not want to learn or practice. Despite this practice often appearing to be intelligent critical evaluation, it is just an example of cherry-picking by dismissing all research that does not support the individual's confirmation bias. It is a way to rationalize an individual's current practice, so they do not need to put in the effort to improve (studying, learning, practicing, and refining based on outcomes). It is laziness.

Most issues in physical rehabilitation and movement science are relative choices; that is, a decision must be made between 2 or more interventions. Most often we need a solution, so choosing the best solution is better than not choosing a solution at all. This includes choices in which the best available option is not as reliable, accurate, or effective as we would like. Often "excuse-driven therapists" will dismiss an intervention, without acknowledgment that their only alternative is their own untested methods which are based on nothing more than opinion and anecdotal evidence. This is not science; again, this is confirmation bias.

Condemning a technique or assessment without a better alternative is irresponsible education.

As discussed below, research demonstrates that the SIJ moves enough to be reliably palpable, SIJ dysfunction can be the origin of low back pain, there is a researched reliable special test and test-item cluster for assessing SIJ motion, and studies demonstrate that mobilization and manipulation techniques significantly alter motion and improve outcomes. Additional, studies that may be related to these issues include research demonstrating SIJ pain can be reliably assessed , SIJ dysfunction may contribute to lumbo pelvic hip complex dysfunction (LPHCD) , and mobilizations are relatively safe when compared to other potential treatment options (e.g. exercise, NSAIDs, surgery, etc.). In summary, the research suggests, that even if palpation and motion assessment were not reliable, it is likely safer to attempt SIJ treatment when indicated, knowing that a significant portion will attain benefits, and those who do not are incredibly unlikely to exhibit any deleterious effects. This article uses an evidence-based approach to bust many SIJ myths, and demonstrate that dismissing assessment and treatment of the SIJ is likely to make patient outcomes worse.

Summary

  • Does the SIJ Move? - Most SIJ motion occurs in the sagittal plane around a transverse axis, with an average of 1.6° of rotation (range: 0.8° - 6.0°), and an average translation of 0.7 mm (range: 0.1 - 2.0 mm). The amount of SIJ motion is likely similar to lumbar facet motion, and no more challenging to palpate.
  • Does the SIJ Contribute to Low Back Pain? - Several studies have demonstrated that the SIJ can be the origin of low back pain symptoms, especially when accompanied by pain in the Fortin Area and other signs of SIJ dysfunction.
  • Does SIJ Dysfunction Alter Motion? - The myth that pain and SIJ motion are not correlated likely originates from the weak correlation between pain, sacral position, total laxity (stiffness), and changes in laxity. However, pain may be strongly correlated with asymmetric SIJ laxity.
  • Does Mobilization and Manipulations Improve SIJ Motion? - It is unlikely that manipulation results in a change in sacral position; however, mobilizations and manipulations are likely to reduce SIJ pain, reduce positive SIJ special test results, increase SIJ mobility, and reduce altered pelvic and lumbar spine position. Note, that these studies are congruent with the assertion that SIJ dysfunction is not correlated with sacral position, but may be correlated with asymmetric stiffness (laxity) and asymmetric pelvic position.
  • Can We Assess Sacroiliac Joint Motion? - If the focus of the assessment is directed toward the identification of asymmetric stiffness/laxity, then there is a special test and potentially a test-item cluster that research has demonstrated exhibits good or better reliability and accuracy.

Additional Courses:

Additional Manual Therapy Articles

Sacroiliac Joint (SIJ) Mobilization with "saddle grip" or "pisiform/hamate grip" (Grade III or IV, Posterior to Anterior - PA Mobilization)
Caption: Sacroiliac Joint (SIJ) Mobilization with "saddle grip" or "pisiform/hamate grip" (Grade III or IV, Posterior to Anterior - PA Mobilization)

Does the Sacroiliac Joint (SIJ) Move?

Some professionals have claimed that the SIJ does not move or only moves a small amount. However, research studies have used relatively sophisticated techniques to analyze the motion of the sacroiliac joint (annotated bibliography below). These techniques include externally fixated markers and analysis by a 3-dimensional goniometric system (1), 3-dimensional stereophotogrammetry using externally visible bone pins anchored percutaneously with analysis by conventional light photography (2), and roentgen stereophotogrammetry using small radio-opaque markers implanted in the bone and tracked with 2 synchronized x-rays (3-6). These methods have demonstrated that most SIJ motion occurs in the sagittal plane around a transverse axis, with an average of 1.6° of rotation (range: 0.8° - 6.0°), and an average translation of 0.7 mm (range: 0.1-2.0 mm). A systematic review by Cardwell et al. included 176 total records, and 13 peer-reviewed publications (many of the same studies included in this review), demonstrating the SIJ exhibited an average of 1.88° of rotation during lumbar spine flexion/extension, 0.85° of rotation during lumbar spine lateral flexion, and 1.26° of rotation during lumbar spine rotation (7). In summary, these studies demonstrate that the SIJ exhibits statistically significant amounts of movement; however, it may be easy to dismiss these small numbers without a reference to compare them to.

How much is 2 mm and 1.6° of rotation?

It is easy to see 2 - 6° of rotation, or translation of 0.1 - 2.0 mm, and think that this small motion 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 of 2–4 mm (8). There are very few practitioners who would argue whether lumbar facet motion is palpable; and yet, these averages are remarkably similar to the averages reported for SIJ motion. 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 the reading speed and comprehension of the blind. Lei et al. demonstrated that when blind adults were tested with the lowest braille heights of 0.04mm, about 1/5 the amount of the lowest range for SIJ translation reported in the studies above, more repeated motions over words and slower reading speeds occurred. However, repeated movements and reading speed were normal at medium and high braille heights (0.18 and 0.38mm), which are similar to the lowest ranges for translation reported in the studies above (9). 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 many times smaller than the lowest range reported and exponentially smaller than the average amount of SIJ motion reported in most studies. Although palpation and assessment of SIJ motion may be challenging, it is likely reasonable to conclude that SIJ motion is no more challenging to palpate than lumbar facet motion, and well within the limits of fingertip sensitivity.

Does the Sacroiliac Joint (SIJ) Contribute to Low Back Pain?

Several studies have used injections to demonstrate that SIJ dysfunction is a cause of low back pain. A study by Fortin et al. compared 10 asymptomatic volunteers who received injections of contrast material followed by xylocaine into the right SIJ. The area of hypesthesia (reduced pain sensitivity) was then mapped by the researchers and participants, detailing an area extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine. This area is now known as the "Fortin Area" (10). Additional studies have demonstrated that low back pain patients receiving anesthetic injections into the sacroiliac joint (especially those with pain reported in the "Fortin area" and other signs of SIJ dysfunction) exhibit a reduction in symptoms, an increase in function, an improvement in work status, and a trend toward less drug use (11-13). Note, that 1 of the studies cited below demonstrated that an injection did not result in improvements in outcomes; however, this study specifically mentions the use of prescribed opioids by the participants, which may have contributed to less additional benefit from anesthetic injection (14). These studies suggest that the sacroiliac joint can be the origin of low back pain symptoms, especially when accompanied by pain in the Fortin Area and other signs of SIJ dysfunction.

Does Sacroiliac Joint (SIJ) Dysfunction Alter Motion?

The assertion that pain and dysfunction are not correlated with sacroiliac joint motion is a myth. However, the relationship may not be intuitive, and the assertion that no relationship exists was likely an easy conclusion to develop without a careful review of all available research. Several studies have demonstrated that pain and dysfunction are not correlated with average SIJ laxity or changes in laxity (15 - 19). Further, additional studies demonstrate that pain may be correlated with less SIJ motion (15) or more SIJ motion (16) (conflicting findings?). However, it is a study by Buyruk et al. that gives the first clue toward a stronger correlation between pain and SIJ motion. In a study investigating peripartum women with and without pelvic and low back pain, it was not more or less average laxity, but asymmetric SIJ laxity that was most strongly correlated with pelvic/low back symptoms (17). Further, another study by Damen et al. demonstrated that asymmetric laxity had a sensitivity of 65%, specificity of 83%, and a positive predictive value of 77% for identifying moderate to severe pelvic pain that persisted postpartum (18). Providing additional support for the asymmetric stiffness hypothesis, Cibulka et al. demonstrated patients with low back pain without evidence of SIJ dysfunction had more hip external ROM than internal ROM bilaterally; however, those with evidence of SIJ dysfunction had significantly more hip external ROM than internal ROM unilaterally, specifically on the side of the posterior innominate. (Note, this study and clinical outcomes are why the Brookbush Institute recommends the Overhead Squat Assessment and an "asymmetrical weight shift " as the "top tier assessment" to implicate SIJ dysfunction). These studies suggest that the myth that pain and SIJ motion are not correlated likely originates from the weak correlation between pain, sacral position, total laxity (stiffness), and changes in laxity; however, pain may be strongly correlated with asymmetric SIJ laxity.

Does Mobilization and Manipulations Improve Sacroiliac Joint (SIJ) Motion?

Studies have demonstrated that sacral position is unlikely to change following mobilization and manipulation; however, pelvic motion, pelvic position, and SIJ symptoms are likely to improve. Tullberg et al. compared 10 individuals with unilateral sacroiliac joint dysfunction before and after sacroiliac joint manipulation. The findings demonstrated no change in sacral position in standing measured with roentgen stereophotogrammetric analysis; however, the number of positive test results decreased significantly for 12 sacroiliac joint special tests (20). An RCT by de Toledo et al. compared 30 physically active asymptomatic males before and after manipulation, demonstrating a trend toward improvements in SIJ mobility that suggests the study may have been too small to reach statistical significance (21). An RCT by Cibulka et al. compared 20 males and females (age: 26 ± 11 years) with non-specific low back pain and assessed sacroiliac joint dysfunction (positive on 3 of 4 commonly used SIJ special tests) and demonstrated that SIJ manipulation resulted in a significant change toward normalization of the pelvic tilt, including an equal and opposite pelvic tilt of the contralateral side (22). Last, Mahmoud et al. compared 30 males and females (age: 20 - 40 years) with low back pain, an anterior pelvic tilt, and hyper-lordosis of lumbar spine, demonstrating that SIJ manipulation resulted in a significant difference in average pain (5.8±1.44 to 5.03±1.32), average anterior pelvic tilt (8.86° ± 0.77 and 4.86° ± 0.68), and a reduction in the hyper-lordosis (23). Based on these research studies, it is unlikely that manipulation results in a change in sacral position; however, mobilizations and manipulations are likely to reduce SIJ pain, reduce positive SIJ special test results, increase SIJ mobility, and reduce altered pelvic and lumbar spine position. Note, that these studies are congruent with the assertion that SIJ dysfunction is not correlated with sacral position, but may be correlated with asymmetric stiffness (laxity) and asymmetric pelvic position.

Sacroiliac Joint Mobility Techniques:

Can We Assess Sacroiliac Joint Motion?

Many articles and blogs admit that SIJ pain can be assessed using Laslett's Cluster , but most also claim that SIJ motion cannot be assessed. This may be due to studies that demonstrate a lack of reliability and accuracy from special tests that attempt to asses SIJ ROM or sacral position. As mentioned above, this should not be surprising as studies using advanced imaging techniques have demonstrated that sacral position is unlikely to significantly change, and total SIJ ROM is not strongly correlated with SIJ pain. These tests may be attempting to identify weakly correlated signs (signs that do not consistently accompany SIJ dysfunction), and exhibit the poor reliability and accuracy that is provided when attempting to identify inconsistent data.

However, if the focus of the assessment is directed toward the identification of asymmetric stiffness/laxity, then there is a special test and potentially a test-item cluster that exhibits good or better reliability and accuracy in several research studies. Admittedly, identifying this assessment method requires both a change in what is being assessed, as well as an analysis of the entire body of research on SIJ special tests. Although it is beyond the scope of this article, a comprehensive review of SIJ special tests is discussed in the course: Special Tests: Sacroiliac Joint (SIJ) .

The special test that has demonstrated moderate to good reliability in several research studies is the Gillet test (a.k.a. Stork Test) ; however, it should be noted that this test should be performed with consideration of the previously discussed research. A study by Hungerford et al. demonstrated good interrater reliability when assessing whether the SIJ moved (2-point scale; yes or no) and moderate interrater reliability when assessing SIJ movement direction (3-point scale; none, up, down) (24). Although additional studies have demonstrated moderate or better reliability (Special Tests: Sacroiliac Joint (SIJ ), some texts have discussed using the Gillet test to assess position and demonstrated poor reliability. At this point in this article, this should not be surprising. What is needed from the Gillet test is closer to the 2-point scale (yes or no) described by Hungerford et al. That is, each side is assessed with the question "Does it move?", and the two sides are compared. The goal of the assessment should be to identify asymmetries in stiffness. Our findings from the Gillet test should be "More Motion Right," "More Motion Left," or "Equal."

Additionally, an interesting study by Grieve et al. demonstrated that a test cluster  including the Gillet Test , Hip Rotation ROM  with 90° of hip and knee flexion , and palpation of the superior ligament of the symphysis pubis were reliable for identifying individuals with SIJ dysfunction. The participants in this study had been referred by a physician due to complaints of low back pain, and part of the successful identification of SIJ dysfunction was a positive response to SIJ manipulation (in conjunction with education on living modifications and a progressive walking program) (25). Interestingly, this cluster combines the most reliable movement assessment, with the identification of asymmetry as previously mentioned in the study by Cibulka et al. (22), and pain on palpation which has relatively high specificity for identifying SIJ-specific pain (Special Tests: Sacroiliac Joint (SIJ ).

The Brookbush Institute has used this research to develop a relatively simple evidence-based SIJ assessment and treatment protocol. Further research is recommended; however, clinical outcomes have exhibited excellent reliability and efficacy. Note, that the Brookbush Institute recommends starting with the Overhead Squat  Assessment (OHSA). This may be considered separate from the actual "SIJ Cluster", and is a "top tier" assessment used to identify which segment should be addressed. The SIJ assessment cluster is recommended if the client or patient exhibits an "asymmetrical weight shift " originating from the lumbopelvic hip complex (with heel rise), during the OHSA.

Brookbush/Grieve Recommended Movement Cluster:

Assessment:

Treatment

Additional Assessment Courses (with more detailed sample programs for treatment):

Dr. Brookbush, DPT demonstrates the "Chicago Technique" for sacroiliac joint (SIJ) manipulation.
Caption: Dr. Brookbush, DPT demonstrates the "Chicago Technique" for sacroiliac joint (SIJ) manipulation.

Annotated Bibliography:

  1. Wilke et al. compared 12 sacroiliac joints of 6 patients with radiologically normal joints using Schanz screws implanted in S1 and the ilium, and measured continuously with a 3-dimensional goniometric system. The findings demonstrated that the maximum rotation angle of the sacrum occurred primarily in the sagittal plane during end-range hip extension, and was 1.3° on the right and 1.6° on the left (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 Grenzgebiete, 135(6), 550-556.
  2. Studies by Jacob et al. and Kissling et al. compared the sacroiliac joint motion of 15 males and 9 females (age: 20 - 50 years) using the 3-dimensional stereophotogrammetric method (percutaneously introduced external markers and conventional light photography). Measurements were obtained from an upright standing posture through the 3 planes of motion. The average value for rotation was 1.7°, and translation was 0.7 mm. One participant with known recurrent sacroiliac joint symptoms exhibited 6° of rotation. No statistically significant differences were exhibited between genders, ages, or pregnancy history.
    • 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 Biomechanics, 10(7), 352-361.
    • 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.
  3. Egund et al. compared the sacroiliac joint motion of 21 females and 4 males using roentgen stereophotogrammetry (Small radio-opaque markers implanted in bone and tracked with 2 synchronized x-rays). The findings demonstrated that the sacrum moved primarily around a transverse axis with a mean rotation of 2.5° (range: 0.8°-3.9°), and a mean translation of 0.7 mm (range: 0.1-1.6 mm). Statistically significant differences were not exhibited between symptomatic and asymptomatic joints.
    • Egund, N., Olsson, T. H., Schmid, H., & Selvik, G. (1978). Movements in the sacroiliac joints were demonstrated with roentgen stereophotogrammetry. Acta Radiologica. Diagnosis, 19(5), 833-846.
  4. Struesson et al. (1989) compared 25 patients (21 females, 4 males) with sacroiliac joint disorders were studied with roentgen stereophotogrammetry in physiologic and extreme positions. Motion remained consistent under different loads, and occurred primarily around a transverse axis, including average rotation of 2.5° (range: 0.8°-3.9°), and average translation of 0.7 mm (range: 0.1-1.6 mm).
    • Sturesson, B. E. N. G. T., Selvik, G. Ö. R. A. N., & Uden, A. (1989). Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine, 14(2), 162-165.
  5. Struessen et al. (2000) compared 6 women with chronic posterior pelvic pain after pregnancy (n = 5) and sacroiliitis (n = 1) following radio-stereometric analysis (markers implanted in bone and tracked with bi-planer x-rays) in a sustained reciprocal straddle position. Patients exhibited sacroiliac joint motion with a total range of 1.6 - 6° or rotation, and 0.1 - 2.0 mm of translation.
    • Sturesson, B., Uden, A., & Vleeming, A. (2000). A radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. Spine, 25(2), 214.
  6. Another study by Struessen et al. (2000) compared 22 patients considered to have sacroiliac pain following radio-stereometric analysis (markers implanted in bone and tracked with bi-planer x-rays) during the standing hip flexion test (Stork Test?). This study demonstrated that the sacroiliac joint exhibited an average rotation of 0.2°; a rotation range of 0.6°, a translation average of 0.3 mm, and a motion from supine to standing -1.0° to 1.2° of total rotation (average 2.2° total rotation).
    • Sturesson, B., Uden, A., & Vleeming, A. (2000). A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine, 25(3), 364-368.
  7. Cardwell et al. performed a systematic review of sacroiliac joint motion studies; 176 total records, and 13 peer-reviewed publications were identified for review. The average amount of SIJ ROM concluded from the systematic review is similar to those values noted in the original research studies above (some of which were included in this review); 1.88° of rotation in flexion/extension, 0.85° of rotation in lateral bending, 1.26° of rotation in axial rotation.
    • Cardwell, M. C., Meinerz, C. M., Martin, J. M., Beck, C. J., Wang, M., & Schmeling, G. J. (2021). A systematic review of sacroiliac joint motion and the effect of screw fixation. Clinical Biomechanics, 85, 105368.
  8. Kozanek et al. compared 11 healthy subjects who underwent magnetic resonance imaging (MRI) to obtain 3-dimensional models of the L2 - L5 lumbar vertebrae, and were then scanned using a dual-fluoroscopic imaging system while positioning the body in maximal forward-backward bending, side-to-side bending, and maximal left-right rotation. The findings 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 of 2–4 mm.
    • 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. Spine, 34(19), E689-E696.
  9. Lei et al. compared 4 male and 8 female blind adults (age: 41 ± 13.94, range: 22 to 70 years) with average braille reading speeds. The findings 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 (0.18 and 0.38mm)
    • Lei, D., Stepien-Bernabe, N. N., Morash, V. S., & MacKeben, M. (2019). Effect of modulating braille dot height on reading regressions. PloS one, 14(4), e0214799.
  10. Fortin et al. compared 10 asymptomatic volunteers who received injections of contrast material followed by xylocaine into the right SIJ and were examined for mapping of an area of hypesthesia (reduced pain sensitivity). The examination revealed an area extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine (Fortin area). In a follow-up study, 16 patients were selected whose pain most closely matched the "Fortin area". All 16 patients exhibited pain provocation with injection into the symptomatic sacroiliac joint. Further, 10 of these individuals also received lumbar discography and lumbar facet injections, and only the SIJ injection provoked symptoms (confirming the "Fortin area" was related to increased SIJ sensitivity and lumbar facet sensitivity).
    • 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. Spine, 19(13), 1475-1482.
    • 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 evaluation. Spine, 19(13), 1483-1489.
  11. Van der Wurff et al. selected 60 participants meeting diagnostic criteria for sacroiliac joint dysfunction, from 140 consecutive patients with chronic low back pain. The intensity and area of pain were mapped for all participants, and all received a double diagnostic fluoroscopically guided intra-articular sacroiliac joint block. 27 responded with a reduction in pain and 33 patients did not. The findings suggest that there were no significant differences in the mapped 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% exhibiting more intense pain at the ischial tuberosity.
    • 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 therapeutics, 29(3), 190-195.
  12. Maigne et al. compared 54 participants with unilateral low back pain, pain mapping compatible with a sacroiliac joint origin (Fortin area), tenderness over the sacroiliac joint during pain provocation tests, and no obvious source of pain in the lumbar spine. All participants received a double diagnostic fluoroscopically guided intra-articular sacroiliac joint block. A second examination consisting of the same tests assessed the efficacy of the first block, and participants then received a confirmatory block. 19 patients had a positive response to the first block (35%), and of those 10 (18.5%) were temporarily relieved by the confirmatory block.
    • 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. Spine, 21(16), 1889-1892.
  13. A retrospective study by Slipman et al. examined 31 men and women (age: 22 – 80 years) diagnosed with sacroiliac joint dysfunction with no history of spondyloarthropathy, psoriasis, neuromuscular deficits, etc. The participants received a fluoroscopy-guided diagnostic sacroiliac joint block. Outcome measures included changes in Oswestry Disability Index (ODI) scores, pain score on the Visual Analog Scale (VAS), work status, and medication usage 2 years after the intervention. The findings demonstrated the fluoroscopy-guided sacroiliac joint block resulted in a significant decrease in ODI scores, and VAS pain scores, an improvement in work status (more patients went into full-time work), and a trend toward decreased drug usage.
    • 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 & rehabilitation, 80(6), 425-432.
  14. A prospective RCT by Soneji et al. compared 40 participants (age: 18 – 85 years) clinically diagnosed with unilateral sacroiliac joint disease, tested positive on at least three physical examination maneuvers for sacroiliac dysfunction, exhibited moderate-to-severe pain (> 3) on the numerical rating score (NRS), and/or used opioid analgesic therapy. The participants were (evenly split and) randomly assigned to an ultrasound-guided injection group or a fluoroscopy-guided injection group. Outcome measures included limitation of physical functioning measured by the Oswestry Disability Index (ODI) 1 month after the intervention, daily opioid intake, and differences in NRS pain score at 24 hours, 72 hours, 1 week, 1 month, and 3 months after the study. An additional outcome measure included the duration of the injection and patient comfort. The findings demonstrated that neither the ultrasound-guided injection group nor the fluoroscopy-guided injection group resulted in differences in ODI, daily opioid intake, or NRS pain scores at any of the included follow-up times. The findings demonstrated no difference in patient discomfort between the injections, however, the fluoroscopy-guided injection resulted in significantly less time to complete the procedure.
    • 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 Practice, 16(5), 537-544.
  15. Kibsgård et al. compared 1 male and 11 females (age: 29 - 47 years) with pelvic girdle pain localized at one or both sacroiliac joints, who tested positive on at least 2 of 5 clinical tests (posterior pelvic pain test, active straight leg raise test , palpation of long dorsal sacroiliac joint, modified Trendelenburg test, and palpation of the pubic symphysis). All patients performed the Active Straight Leg Raise Test 2 - 3 weeks after sacroiliac joint fusion surgery. Outcome measures included the mean backward and forward motion of the sacroiliac joint on both the lifted side leg and resting side leg during the active straight leg raise test (ASLR) . The findings demonstrated that the sacroiliac joint on the lifted side leg exhibited nearly no motion, and the resting leg exhibited an average of 0.8° of posterior rotation and 0.3° inward tilt.
    • 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 Biomechanics, 47, 40-45.
  16. Adhia et al. compared 122 low back pain patients (age: 18 - 50 years) with no history of surgery or trauma to the spine, torso, or lower extremity injury in the previous 12 months, no signs of systemic or congenital abnormalities, and not currently pregnant. Participants were split into three groups (SIJ-negative, SIJ-positive right side, SIJ-positive left side) based on Laslett's Cluster II: Sacroiliac Joint Pain Test-item Cluster , with ≥3 positive tests = SIJ-positive. The participants performed passive (manually positioned by the therapist) prone-lying hip abduction and external rotation (HABER) from neutral (0°) to end-range (50°) in increments of 10°. The findings demonstrated that SIJ-positive sides exhibited greater innominate movement and a trend toward rotation during an active straight leg raise test when compared to SIJ-negative sides. However, the differences in total ROM were not statistically significant for any group.
    • 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 therapy, 21, 100-108.
  17. Buyruk et al. compared 56 peripartum women (age: 33.1 ± 5.6 years) at least 3 months post-delivery with pelvic and/or low back pain and 52 women (age: 34.5 + 5.8 years) with no history of pelvic and/or low back pain. All participants were assessed for sacroiliac joint laxity with Doppler imaging of vibration. Outcome measures included SIJ stiffness categorized into 3 groups (low stiffness, high stiffness, or asymmetric stiffness). The findings demonstrated no statistical significance when comparing groups based on average stiffness, low stiffness only, or high stiffness only. However, the pelvic pain group exhibited a significantly higher prevalence of asymmetric SI joint stiffness than the no-pain group (including a correlation between asymmetric SIJ stiffness and pelvic pain).
    • 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 Biology, 83(2), 159-163.
  18. Damen et al. compared 123 female hospital patients (age: 31.3 ± 6.0 years) with no history of low back and/or pelvic pain before pregnancy, no pain radiating below the knee, no congenital anomalies of the spine, no rheumatologic disease, and no evidence of twin pregnancy. All participants were assessed with Doppler imaging of vibration on the pelvis at 36 weeks of pregnancy and 8 weeks postpartum. A left-to-right difference in sacroiliac joint laxity of 3 or more threshold units was considered an indication of significant asymmetry. The participants exhibited greater sacroiliac joint laxity at 36 weeks of pregnancy when compared to 8 weeks postpartum, and average laxity was not different between asymptomatic and symptomatic participants. However, asymmetric laxity had a sensitivity of 65%, specificity of 83%, and a positive predictive value of 77% for identifying moderate to severe pelvic pain that persisted postpartum.
    • 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. Spine, 27(24), 2820-2824.
  19. Cibulka et al. compared 76 men and women (age: 39 ± 14 years) with low back pain and an indication of sacroiliac joint dysfunction, and 24 men and women (age: 39 + 14 years) with low back pain and no indication of sacroiliac joint dysfunction. All participants were assessed with 3 trials of goniometry of passive hip external and internal rotation range of motion. The findings demonstrated patients with low back pain without evidence of SIJ dysfunction had more hip external ROM than internal ROM bilaterally; however, those with evidence of SIJ dysfunction had significantly more hip external ROM than internal ROM unilaterally, specifically on the side of the posterior innominate.
    • 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.
  20. Tullberg et al. compared 10 patients with positive test results on the majority of 12 SIJ special tests, confirming the diagnosis of unilateral SIJ dysfunction. All participants received sacroiliac joint manipulation, followed by reassessment with the same special tests, and assessments of the position of the sacrum relative to the ilium via roentgen stereophotogrammetric analysis. Following manipulation, all participants exhibited a significant reduction in the number of positive test results; however, there was no significant change in the relative position of the sacrum.
    • Tullberg, T., Blomberg, S., Branth, B., & Johnsson, R. (1998). Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine, 23(10), 1124-1128.
  21. de Toledo et al. compared 30 physically active asymptomatic males (age: 18 - 35 years) participating in at least 30 mins of activity/day with no history of lumbar spine or pelvic girdle surgery, sacroiliac joint therapy, adverse reactions to adhesive tape, differences in leg length, balance deficits, or motor deficits in the muscles of the lower leg. Participants were randomly assigned to a control group (placebo manipulation) or a group receiving an osteopathic manipulation of the anterior ilium bone, during hip flexion (high-velocity, low-amplitude). SIJ motion was assessed with a 3-dimensional motion analysis system. The findings demonstrated a trend, that failed to reach statistical significance, toward increased mobility of the SIJ following manipulation, and a difference between manipulation and placebo control groups.
    • de Toledo, D. D. F. A., Kochem, F. B., & Silva, J. G. (2019). High-velocity, low-amplitude manipulation (HVLA) does not alter the three-dimensional position of the sacroiliac joint in healthy men: A quasi-experimental study. Journal of Bodywork and Movement Therapies.
  22. Cibulka et al. compared 20 males and females (age: 26 ± 11 years) with non-specific low back pain and assessed sacroiliac joint dysfunction (positive on 3 of 4 tests commonly used SIJ special tests) randomly assigned to a control group (no intervention) or a sacroiliac joint manipulation group. The findings demonstrated that compared to controls, the manipulation group exhibited a significant change toward normalization of the pelvic tilt, including an equal and opposite pelvic tilt of the contralateral side.
    • 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 Therapy, 68(9), 1359-1363.
  23. Mahmoud et al. compared 30 males and females (age: 20 - 40 years) with low back pain measured with a visual analog scale, an anterior pelvic tilt measured with an inclinometer, and hyper-lordosis of the lumbar spine measured with photographic analysis (surgimap software). All participants received an SIJ joint manipulation (Chicago manipulation). The findings compared pre- and post-treatment assessment, demonstrating a significant difference in average pain (5.8±1.44 to 5.03±1.32), average anterior pelvic tilt (8.86° ± 0.77 and 4.86° ± 0.68), and a reduction in the hyper-lordosis.
    • 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 Research, 48(1), 87-95.
  24. Hungerford et al. compared three experienced physical therapists (age: 37-42) with a mean of 14.7 years of experience randomly assigned to palpate the motion of the sacroiliac joint during the Stork Test in 33 test participants (age: 36.2 + 13.4 years). Outcome measures included the interrater reliability of assessing whether SIJ movement occurred (2-point scale; yes or no) and the interrater reliability of assessing the direction SIJ movement occurred (3 point-scale; none, up, down). The findings demonstrated moderate interrater reliability when assessing using the 3-point scale, and good interrater reliability in when assessing using the 2-point scale.
    • 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 Therapy, 87(7), 879-887.
  25. A retrospective analysis by Grieve et al. investigated 57 patients referred to their general practitioner with back and/or leg pain. Participants were assessed with a combination of a modified Gillet's test, passive hip rotations in supine with 90 degrees of hip and knee flexion, and palpation of the superior ligament of the symphysis pubis. Findings demonstrated good specificity and sensitivity of the combination of the 4 tests. Further, all patients regained normal pain-free function after manipulation of the sacroiliac joint(s) followed by a program of modified living and progressively increased walking.
    • Grieve, E. (2001). Diagnostic tests for mechanical dysfunction of the sacroiliac joints. Journal of Manual & Manipulative Therapy, 9(4), 198-206.


© 2023 Brent Brookbush (B2C Fitness, LLC d.b.a. Brookbush Institute)

Comments, critiques, and questions are welcome!

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