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Special Tests: Sacroiliac Joint (SIJ) Audio

Special tests for the sacroiliac joint (SIJ). The Sacral Thrust Test, Compression Test, Distraction Test, Thigh Thrust Test, Gaenslen's Test, the Stork/Gillet Test (Laslett's Cluster II: Sacroiliac joint pain test-item Cluster), and the FABERs (Patrick) Test. The reliability, specificity, sensitivity, validity, safety, and screening for sacroiliac joint (SIJ) pathology, sacroiliac joint pain, pelvic fracture, and SI joint stiffness.  

Special Tests: Sacroiliac Joint (SIJ)

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

Additional Pain Provocation Tests (not included in test):

Appendix: Research Review on SIJ Movement Assessment

Sacroiliac joint dysfunction (a.k.a. SIJD, SI joint dysfunction, SI joint syndrome, SI joint pain) may result from movement impairment, acute injury, or trauma, and is often mistaken for lower back pain or develops concurrently with lower back pain. Due to controversy regarding the amount of motion that occurs at the SI joint, and the relative strength of the ligaments and connective tissue that support these joints, conservative treatment options are often dismissed. It is common that patients and clients will not receive treatment for symptoms until they are complaining of chronic pain; for example, nerve (e.g. "patient complains of pinched nerve"), ligament (e.g. pain with forward bending), or connective tissue (e.g. continuous dull ache) inflammation. Most often, clinical movement professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) are the safest and most effective option for pain relief (e.g. manual therapy, certain modalities, and corrective exercise).

Most palpation, motion, and position assessments for the sacroiliac joint (SIJ) have questionable reliability. However, research has demonstrated that 

 is reliable and accurate for diagnosing the sacroiliac joint as a source of pain (4, 5, 22, 23). It is worth noting that SIJ pain provocation tests are more specific than sensitive (4 - 21), indicating a positive result carries more weight than a negative result. In summary, a positive result using 

 is strongly indicative that pain is originating from SIJ dysfunction.

A review of SIJ movement assessment research is included in this course. The intent of the review is the suggestion of a possible cluster for identifying dysfunctional/altered motion. The research has demonstrated that the 

 is reliable when confined to a narrow set of findings (24), and one observational study by Grieve et al. (70) demonstrated good reliability and accuracy from a grouping of findings. Additional refinements to the Grieve et. al grouping can be made based on additional research and may imply a useful SIJ movement assessment cluster.

 recommends that all clinical professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) are aware of 

. However, in practice, pain provocation has little utility for improving clinical decision-making and refining intervention selection. In practice, the 

 recommends evidence-based modifications to the Grieve et al. cluster to determine the less and more mobile sides, and to treat the SIJ according to their relative stiffness (mobilize/manipulate the stiff side, glute activation on the more mobile side). 

Brookbush/Grieve (70) Recommended Cluster:

"Top tier exam" used to identify asymmetry and imply further SIJ assessment

Unilateral Pelvic Tilt: Posterior tilted innominate correlated with stiffer side

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, accuracy (specificity, sensitivity, reliability, etc.), how we chose the tests in each special test course lessons, and best practice recommendations:

Courses covering Special Tests for the Lumbo Pelvic Hip Complex

Special Tests: Lower Body Neurodynamic Tests

Course Description: Special Tests: Sacroiliac Joint

Course Study Guide: Sacroiliac Joint (SIJ) 

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:

Introduction

The patient lies in a prone position and is asked about current symptoms.

The examiner then palpates the midpoint of the sacrum by "falling off" the posterior superior iliac spine (PSIS) medially.

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.

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.

It the test reproduces the concordant sign the test is positive.

The patient assumes a side-lying position with painful side up, and is asked about current symptoms.

The examiner then cups the top side iliac crest with both hands to reduce help spread force over a larger surface area

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.

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.

If the test reproduces the concordant sign the test is positive.

Distraction Test (Anterior Sacroiliac Joint Stress Test):

The patient assumes a supine position and is asked about current symptoms.

The examiner palpates the medial side of both anterior superior iliac spine (ASIS).

The examiner crosses their arms, resulting in an "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.

The examiner then applies a downward (spreading the anterior sacroiliac joint) 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.

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

The examiner stands opposite the painful side of the patient.

The hip on the painful side is flexed to 90 degrees, and the examiner uses the hand closest to the patient's head to pull the leg and tip the patient's hips and pelvis closer to them.

The examiner then slides their other hand under the sacrum, so the palm is firmly cupping the majority of the sacrum.

The patient is then tilted back over the examiner's hands, so the examiner's hand is now creating a stable platform for the sacrum to sit on.

The examiner then uses the thigh of the painful side to apply a vigorous downward force in an attempt to shear the ilium.

If the test reproduces the concordant sign near the sacroiliac joint on the tested side, the test is positive.

The patient assumes the "Thomas Test Position" - A supine position at the end of a table with one leg clutched to the 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 the 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.

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 a 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.

Once the examiner is comfortable, and in a position to apply these forces, up to 6 thrusts are performed while asking the patient about their current symptoms.

If 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.

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

3 out of 5 tests are indicative of SIJ pain and dysfunction. Note: This cluster is not included on the exam associated with this course because the sensitivity of 85% and a specificity of 79% is lower than the 

Sacral Thrust, Compression, and Distraction

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

The patient starts in a standing position with feet shoulder-width apart.

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.

The examiner then asks the patient to flex the hip on the side being palpated, knee to hip height, like a high march.

The examiner monitors the motion of the PSIS relative to the sacrum.

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.

A positive test for SIJ stiffness is elevation, no motion, or less motion than the opposite side.

Appendix: Research Review for the Development of a Movement Cluster

The 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 contributes significantly to 15 – 30% of low back pain cases.

The SIJ are capable of approximately 1.6 - 6° of 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.

 likely alters motion and results in dysfunction and pain; it is unlikely that dysfunction is the result of a change in 

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 

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 pubic symphysis.

Manipulation results in improved SIJ symmetry, hip ROM symmetry, gait symmetry, pain and disability.

Sacroiliac Joint Motion (SIJ) Exam

Research Review Summary 

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

SI Joint Image

SIJ Motion

SIJ Motion Testing

Research Review for the Development of a Movement Cluster

Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.

Dutton's Orthopaedic examination, evaluation, and intervention

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. 

Laslett, M., & Williams, M. (1994). The reliability of selected pain provocation tests for sacroiliac joint pathology. 

Blower, P. W., & Griffin, A. J. (1984). Clinical sacroiliac tests in ankylosing spondylitis and other causes of low back pain--2 studies. 

Ozgocmen, S., Bozgeyik, Z., Kalcik, M., & Yildirim, A. (2008). The value of sacroiliac pain provocation tests in early active sacroiliitis. 

Russell, A. S., Maksymowych, W., & LeClercq, S. (1981). Clinical examination of the sacroiliac joints: a prospective study. 

Arthritis & Rheumatism: Official Journal of the American College of Rheumatology

Kokmeyer, D. J., van der Wurff, P., Aufdemkampe, G., & Fickenscher, T. C. (2002). The reliability of multitest regimens with sacroiliac pain provocation tests. 

Journal of Manipulative and Physiological Therapeutics

Strender, L. E., Sjöblom, A., Sundell, K., Ludwig, R., & Taube, A. (1997). Interexaminer reliability in physical examination of patients with low back pain. 

McCombe, P. F., Fairbank, J. C., Cockersole, B. C., & Pynsent, P. B. (1989). 1989 Volvo Award in clinical sciences. Reproducibility of physical signs in low-back pain. 

Albert, H., Godskesen, M., & Westergaard, J. (2000). Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain. 

Potter, N. A., & Rothstein, J. M. (1985). Intertester reliability for selected clinical tests of the sacroiliac joint. 

Ham, S. J., Van Walsum, A. D. P., & Vierhout, P. A. M. (1996). Predictive value of the hip flexion test for fractures of the pelvis. 

Arab, A. M., Abdollahi, I., Joghataei, M. T., Golafshani, Z., & Kazemnejad, A. (2009). Inter-and intra-examiner reliability of single and composites of selected motion palpation and pain provocation tests for sacroiliac joint. 

Broadhurst, N. A., & Bond, M. J. (1998). Pain provocation tests for the assessment of sacroiliac joint dysfunction. 

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. 

Dreyfuss, P., Michaelsen, M., Pauza, K., McLarty, J., & Bogduk, N. (1996). The value of medical history and physical examination in diagnosing sacroiliac joint pain. 

Gutke, A., Hansson, E. R., Zetherström, G., & Östgaard, H. C. (2009). Posterior pelvic pain provocation test is negative in patients with lumbar herniated discs. 

Ostgaard, H. C., & Andersson, G. B. (1991). Previous back pain and risk of developing back pain in a future pregnancy. 

Bogduk, N. (1999). Pain provocation tests for the assessment of sacroiliac joint dysfunction. 

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. 

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 rehabilitation

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. 

Injection demonstrates contribution of SIJ to low back pain

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. 

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. 

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

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. 

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

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. 

Jacob, H. A. C., & Kissling, R. O. (1995). The mobility of the sacroiliac joints in healthy volunteers between 20 and 50 years of age. 

Kissling, R. O., & Jacob, H. A. (1996). The mobility of the sacroiliac joint in healthy subjects. 

Bulletin (Hospital for Joint Diseases (New York, NY))

Egund, N., Olsson, T. H., Schmid, H., & Selvik, G. (1978). Movements in the sacroiliac joints demonstrated with roentgen stereophotogrammetry. 

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

Cibulka, M. T. (2001). Re: a radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. 

Sturesson, B., Uden, A., & Vleeming, A. (2000). A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. 

Sturesson, B., Uden, A., & Vleeming, A. (2000). A radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. 

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. 

Lei, D., Stepien-Bernabe, N. N., Morash, V. S., & MacKeben, M. (2019). Effect of modulating braille dot height on reading regressions. 

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. 

Sturesson, B. E. N. G. T., Selvik, G., & UdÉn, A. (1989). Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. 

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. 

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

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.

Panjabi, M. M. (1992). The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. 

Panjabi, M. M. (1992). The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. 

Changes in Motion Following Manipulation:

Tullberg, T., Blomberg, S., Branth, B., & Johnsson, R. (1998). Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. 

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. 

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 study. 

Journal of Bodywork and Movement Therapies

Mahmoud, Y. M., Kattabel, O. M. A., & Amin, D. I. (2016). Effect of Posterior Iliosacral Joint Manipulation on Subjects With Hyperlordosis of Lumbar Spine. 

Elgafy, H., Semaan, H. B., Ebraheim, N. A., & Coombs, R. J. (2001). Computed tomography findings in patients with sacroiliac pain. 

Clinical orthopaedics and related research

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. 

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 Surgery

Morgan, P. M., Anderson, A. W., & Swiontkowski, M. F. (2013). Symptomatic sacroiliac joint disease and radiographic evidence of femoroacetabular impingement. 

Fortin, J. D., Vilensky, J. A., & Merkel, G. J. (2003). Can the sacroiliac joint cause sciatica?. 

Schwarzer, A. C., Aprill, C. N., & Bogduk, N. (1995). The sacroiliac joint in chronic low back pain. 

Freburger, J. K., & Riddle, D. L. (1999). Measurement of sacroiliac joint dysfunction: a multicenter intertester reliability study. 

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. 

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 therapies

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. 

Lueck, D. (2009). Reliability of sacroiliac joint tests in experienced and inexperienced examiners.

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. 

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 Therapy

Grieve, E. (2001). Diagnostic tests for mechanical dysfunction of the sacroiliac joints. 

Bibliography

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Special Tests: Sacroiliac Joint (SIJ)

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