Pelvic Anatomy Evaluation & Treatment of the Sacroiliac Joint · Evaluation & Treatment of the...

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Evidence-Based

Evaluation & Treatment

of the Sacroiliac Joint

James R. Scifers, DScPT, PT, SCS, LAT, ATC

Western Carolina University

Athletic Training Education Program

Pelvic Anatomy

Innominates

ischium

ilium

pubis

Sacrum

Important Bony Landmarks

ASIS

PSIS

Pubis

Ischial Tuberosities

Iliac Crests

Greater Trochanters

Articulations

Sacroiliac Joints

Pubic Symphysis

Lumbo-Sacral Joint

Ligamentous & Soft Tissue Structures

Sacrotuberous Ligament

Piriformis

Rectus Femoris

Hamstrings

Gluteus Medius

Erector Spinae

Abdominals

Biomechanics of the Pelvis

Function of the SI Joint

transmit vertical forces

transmit ground

reaction forces

2

Sacral Motions

During trunk flexion…

Initially, sacral flexion occurs (base of sacrum

moves anterior)

Later, sacral extension occurs with continued

trunk flexion (base of sacrum moves posterior)

Arthrokinematics of the SI Joint

Sacral Base (S1)

Sacral Apex (S5)

Flexion (nutation)

occurs during

exhalation

Extension

(counternutation)

occurs during

inhalation

Dysfunction Classification

Sacroiliac Joint (SIJ)

Any injury to SIJ

Ilio-Sacral (IS)

ilium (innominate)

moving on sacrum

Sacro-Iliac (SI)

sacrum moving on ilium

Pubic Shear

Pubic symphysis / Pubic

shear lesion

Ilio-Sacral (IS) Dysfunctions

Named for motion at

PSIS

anterior rotation

posterior rotation

up-slip

down-slip (rare)

in-flare

out-flare

Sacro-Iliac (SI) Dysfunctions

Sacral Rotations

Named for “direction facing on axis”

Forward Rotations

right on right

left on left

Backward Rotations

right on left

left on right

Pubic Shear Lesions

Named for any

movement at pubic

symphysis

Indicates injury to pubic

symphysis

3

Muscular Influences

Hamstrings Tight (posterior rotation) or weak

(anterior rotation)

Iliopsoas / Rectus Femoris Tight (anterior rotation) or weak

(posterior rotation)

Gluteus Medius / Minimus Weak (outflare) or tight (inflare)

Piriformis Stretch (forward sacral rotations)

Abdominals Weak (all SIJ conditions)

SI Evaluation

History*

Observation**

Palpation**

AROM / PROM

MMT

Special Tests*

Neurologic Exam

Evidence-Based Practice (EBP)

Reliability (k) is reproducibility of test results, can be

intra-tester (within one clinician) or inter-tester (between

multiple clinicians)

Sensitivity (sens) is the ability of test to RULE OUT a

condition. The higher the sensitivity, the greater

chance that a NEGATIVE test means the condition is

absent

High sensitivity + negative test = rule condition out (SnNout)

Specificity (spec) is the ability of test to RULE IN a

condition. The higher the specificity, the greater

chance that a POSITIVE test means the condition is

present

High specificity + positive test = rule condition in (SpPin)

Evidence-Based Practice (EBP)

Positive Likelihood Ratio (+LR) indicates the

likelihood that a POSITIVE test means the condition is

present

Negative Likelihood Ratio (-LR) indicates the

likelihood that a NEGATIVE test means the condition

is absent

Strength of Recommendation Taxonomy (SORT)

SORT Category Level of Evidence

Consistent, good-quality, patient-oriented evidence

Inconsistent or limited-quality, patient-oriented evidence

Consensus, disease-oriented evidence,

usual practice, expert opinion, or case series

SORT

A

SORT

B

SORT

C

History

SI pain typically unilateral, may refer

Pain typically localized to involved SI joint Sens = .76, Spec = .47, +LR = 1.4, -LR = 0.511

Pain may increase with trunk rotation, sidegliding, trunk/hip extension or sidelying

MOI may include falling or twisting

MOI more often insidious (48 hour rule to assess for cause)

Aggravating Activities usually includes sitting Sens = .03, Spec = .90, +LR = 0.3, -LR = 1.071

SORT

B

Clinical Application #1: Failure to report pain at the PSIS is a

good predictor for patient NOT suffering from SIJ pathology

Clinical Application #2: Pain increased with sitting is a good

indicator that patient may be suffering from SIJ pathology

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Pain Referral Patterns2-3

Pain Location Frequency Sensitivity Specificity + LR - LR

Lumbar Spine 72% N/A N/A N/A N/A

Buttock1 94% 0.80 0.14 0.9 1.42

Groin1 14% 0.19 0.63 0.51 1.29

Thigh 48% N/A N/A N/A N/A

Lower Leg 28% N/A N/A N/A N/A

Foot 12% N/A N/A N/A N/A

SORT

BClinical Application: Failure to report buttock pain is a

good predictor for patient NOT suffering from SIJ pathology

Observation4-6

Observe for spasm

erector spinae

Observe muscle tone

gluteals

Observe symmetry:

PSIS

Iliac Crests

ASIS

Greater Trochanter

Pubic Tubercle

Palpation4-6

Standing: ASIS

PSIS (k = .13 - .37)

Iliac Crests (k = .23 - .41)

Greater Trochanters

Prone: Sacrum

Inf Lat Angle of Sacrum (k = .69)

Sacral Sulcus (k = .24)

Sacrotuberous Ligament

Piriformis (or sidelying)

Supine: Pubic Tubercle

Palpation Location of Pain1

Locations Sensitivity Specificity + LR - LR

Sacral Sulcus & PSIS 0.49 0.60 1.2 0.85

Sacral Sulcus & Groin 0.11 0.73 0.40 1.22

PSIS & Groin 0.16 0.85 1.10 0.99

SORT

BClinical Application: Patients reporting pain in the region of the

PSIS and the groin are likely to be suffering from SIJ pathology

Piriformis Palpation Sacrotuberous Ligament Palpation

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Alignment & Symmetry

Iliac Crest Heights

higher or lower

PSIS Relationships

superior-inferior

medial-lateral

ASIS Relationships

superior-inferior

medial-lateral

Greater Trochanter

Levels

higher or lower

Sacral Sulcus Depths

deeper or shallower

superior& inferior

Inferior Lateral Angle of

Sacrum

deeper or shallower

Very low inter-tester reliability values (k = .13 - .37) with

exception of inferior lateral angle of sacrum (k = .69)4-6

Active / Passive Range of Motion

AROM tested in standing or sitting

PROM tested in supine or prone

Stress at SI Joint: Spine flexion 40-60°

Spine extension 20-35°

Spine rotation 3-18°

Spine side glide 15-20°

Hip flexion 100-120°

Hip extension 0-15°

SORT

C

Clinical Application: Pain increased with AROM or PROM

Hip Extension to end-range can help differentiate SIJ

pathology from Lumbar Spine pathology

Manual Muscle Testing

As needed (not usually necessary for diagnosis)

Trunk flexion

Abdominals

Hip flexion

Hip abduction

Gluteus Medius

Gluteus Minimus

Hip adduction

Hip extension

Knee flexion

Trunk extension

Bridging

SORT

CClinical Application: Pain increased with bridging is often

indicative of SIJ pathology

Neurologic Assessment

Should be normal in

presence of SI dysfunction

Dermatomes (L1-S2)

Myotomes (L1-S2)

Reflexes

Patellar Tendon (L3-L4)

Achilles Tendon (S1-S2)

Special Tests

Pain Provocation Tests

Straight Leg Raise Test

Gaenslen Test

Thigh Thrust Test

Flamingo Test

FABER / Patrick’s Test

Gapping Test

Compression Test

Sacral Spring / Sacral Thrust Test

SI Rock Test

Positional Tests

Trunk Flexion Test

March Test

Supine to Sit Test

True LLD Test

Apparent LLD Test

Trendelenburg’s Sign

Thomas Test

Special Test Literature

Provocation Tests have little predictive value in isolation or combination1

Inter-tester Reliability of Positional Special Tests is low 6,8

Positional Special Tests performed in combination greatly increase value of findings 7-10

3/6 positive Special Tests (distraction, compression, thigh thrust, Gaenslen, sacral spring) had .91 sensitivity & .78 specificity, + LR = 4.16, - LR = 0.12 7

219 patients, 4 Special Tests (standing flexion, PSIS palpation, supine to sit, prone knee flexion) had .82 sensitivity & .88 specificity, + LR = 6.82, - LR = 0.20 10

SORT

AClinical Application: SIJ special tests should always be

used diagnostically in combination & not in isolation

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Straight Leg Raise Test

Clinician passively flexes hip with knee extended

Pain at 0-30 degrees---hip pathology or nerve root

Pain at 30-50 degrees---sciatic nerve involvement

Limited ROM of less than 70 degrees---hamstring tightness

Pain at 70-90 degrees---sacroiliac joint involvement

All data for detecting lumbar disc herniation, not SIJ pathology11

Sensitivity Specificity + LR - LR

0.78-0.97 0.10-0.57 1.00-1.98 0.05-0.35

Gaenslen Test

Patient is supine with both

legs extended

Uninvolved knee is

brought to chest while

involved hip remains in

extension

Overpressure is applied to

involved side

Positive test is pain

indicating SIJ involvement

K = .54 - .761, 6, 8, 20-21


0.21-0.71 0.26-0.77 0.75-2.21 0.65-1.12

Thigh Thrust Test

Patient is supine

Involved hip is flexion and

adducted

Posterior shearing force is

applied through femur in

varying degrees of hip

adduction / abduction

Positive test is buttock pain

indicating SIJ involvement

K = .64 - .881, 6, 8, 18, 21


0.36-0.88 0.50-1.00 0.70-2.80 0.20-1.28

Flamingo Test

SLS causes or increases

pain on involved side---

may also include buttock

pain

Patient may be asked to

hop on one leg to

increase or cause pain

Positive test is indicative

of SIJ pathology OR

pubic shear lesion


N/A N/A N/A N/A

FABER or Patrick Test

Patient supine with hip positioned

in flexion, abduction and external

rotation

Clinician applies over-pressure at

knee toward table while

stabilizing opposite ASIS

Positive test is pain indicating SIJ

pathology

If patient exhibits a decrease in

pain, an out-flare should be

suspected

K = .60 - .621, 6, 21


0.10-0.77 0.16-1.00 0.41-0.82 0.23-1.94

Gapping or Distraction Test

Patient supine

Clinician applies

crossed-arm outward

pressure on the ASIS

Positive test is pain,

indicating SIJ pathology

If patient reports relief

of pain, an out-flare

should be considered

K = .26 - .691, 6, 8, 18, 21


0.55-0.60 0.81-1.00 3.20 0.49

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Compression Test

Patient is positioned in

supine or sidelying

Clinician applies medial

pressure at iliac crests

to compress ASIS

Positive test is pain

indicating out-flare

Relief of pain indicates

SIJ pathology

K = .26 - .736, 17-20


0.60-0.70 0.69-1.00 2.20-7.00 0.33-1.00

Trunk Flexion Test

Palpate PSIS bilaterally in sitting or standing

Painful PSIS is lower

Painful PSIS rises higher during flexion

Painful PSIS moves first and “most” (PSIS heights are equal at conclusion of test)

Positive test indicates posterior rotation

K = .08 - .68 4-6, 12-14


N/A N/A N/A N/A

Gillet or March Test

Patient brings knee to

chest in either standing or

sitting

Clinician looks for

downward motion of PSIS

Uninvolved side will move

inferiorly, involved side

will move less or not at all

Positive test indicates

posterior rotation

Intra-tester K = .02 – .31, Inter-tester K = .02 - .591, 5-6, 15-17


0.43 0.68 1.3 0.84

Supine to Sit

Patient is supine

Patient performs a bridge

Clinician assesses leg length at

medial malleoli

Patient is instructed to sit up while

applying traction to bilateral lower

extremities

Positive findings are a change in leg

length

posterior rotation: short to long

anterior rotation: long to short

LLD: long to long or short to short


N/A N/A N/A N/AK = .19 10

True Leg Length Measurement

Measured ASIS to medial or lateral malleolus,

indicates bony differences between lower extremities

Apparent Leg Length Measurement

Measured Umbilicus to medial or lateral malleolus,

indicates innominate rotation

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Trendelenburg’s Sign

Patient performs SLS

Clinician observes pelvic

height from behind patient

Inferior movement of iliac

crest on non-stance side

indicates weak gluteus

medius on stance side

This is an associated sign

in presence of out-flare or

SIJ pathologypositive negative


N/A N/A N/A N/A

Thomas Test

Patient is supine at edge of table

Uninvolved knee is passively brought to chest

Positive test is involved lower extremity demonstrating: Hip flexion (tight iliopsoas)

Associated finding with anterior rotation

Knee extension (tight RF) Associated finding with anterior

rotation

Hip abduction (tight ITB/TFL) Associated finding with in-flare


N/A N/A N/A N/A

Sacral Thrust or Sacral Springing

Patient is prone

Clinician applies

downward pressure to

sacrum

Positive test is pain,

indicating sacral rotation

Test can be repeated on

four corners of sacrum

K = .30 - .561, 6, 17-18, 20


0.27-0.75 0.29-1.00 0.75-3.00 0.50-1.62

SI Rock Test

Patient is supine

Clinician passively brings involved knee to opposite shoulder (combination of hip flexion and internal rotation) and applies overpressure

Positive test is buttock pain

Indicating involvement of sacrotuberous ligament

left on right rotation

right on left rotation


N/A N/A N/A N/A

Symphysis Pubis Test

Patient is supine

Examiner places heel of one hand on

superior pubic ramus and heel of other hand on inferior pubic ramus

Examiner applies shearing force to pubic symphysis

Pain indicates pubic shear lesion


N/A N/A N/A N/A

Special Test Take-Home Points

Perform special tests in combination to improve diagnostic

accuracy

Best tests for ruling-in SIJ pathology are FABER, Thigh

Thrust, Gaenslen & Gapping Tests

Best test for ruling-out SIJ pathology is Thigh Thrust Test

Best tests for ruling-in posterior rotation are March &

Supine to Sit Tests

SORT

A

SORT

B

SORT

C

SORT

B

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Special Test Take-Home Points

Best test for ruling-in an outflare is the Compression Test

Best test for ruling-in an SI Dysfunction is the Sacral

Spring Test

Best test for ruling-in a pubic shear lesion is the Flamingo

Test

SORT

B

SORT

C

SORT

B

Treatment Strategies

Muscle Energy

Techniques

Joint Mobilization

Techniques

Stretching Techniques

Strengthening

Techniques

Dynamic Lumbar

Stabilization

Movement / Resistance Key

Isometric Patient Generated Force

Clinician Generated Force

Anterior Rotation

Problem List?

MET

Hamstrings

Joint Mobilizations

Posterior Mobilization

Stretching

Rectus Femoris & Hip

Flexors

Strengthening

Hamstrings & Core

Also may use Scissoring or Arm Break to treat anterior or posterior rotation

SORT

C

Posterior Joint Mobilization Posterior Rotation

Problem List?

MET

Quadriceps

Joint Mobilizations

Anterior Mobilization

Stretching

Hamstrings

Strengthening

Quadriceps & Core

Also may use Scissoring or Arm Break to treat anterior or posterior rotation

SORT

C

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Anterior Joint Mobilization Upslip

Typically secondary to trauma

Problem List?

MET

None

Joint Mobilizations

Inferior Glide / Long Axis Distraction

Stretching

None

Strengthening

None 5 degrees hip flexion, 30 degrees hip

abduction with hip ER or hip IR

SORT

C

In-flare

Problem List?

MET

Adductors

Joint Mobilizations

Out-flare Mobilization

(forced hip adduction

with flexion…SI Rock

Test)

Stretching

ITB & TFL

Strengthening

Adductors & Core

SORT

C Alternate In-flare MET

Out-flare

Problem List?

MET

Abductors

Joint Mobilizations

In-flare Mobilization (force hip abduction with ER…FABER Test)

Stretching

Adductors

Strengthening

Gluteus Medius / Minimus & Core

SORT

C Out-flare Mobilization

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Right on Right Sacrum

Problem List?

MET None

Joint Mobilizations Sacral Springing on

inferior right angle of sacrum

Other Stretch / Treat Right

Piriformis & Strengthen Core

SORT

C Left on Left Sacrum

Problem List?

MET None


inferior left angle of sacrum

Other Stretch / Treat Left

Piriformis & Strengthen Core

SORT

C

Right on Left Sacrum

Problem List?

MET None


superior right angle of sacrum

Other Address left STL pain

& Strengthen Core

SORT

C Left on Right Sacrum

Problem List?

MET None


superior left angle of sacrum

Other Address right STL pain

& Strengthen Core

SORT

C

Sacral Mobilizations Pubic Shear Lesions

Problem List?

MET

Pubic MET

1. Resist abduction in 0

degrees, 2. Resist abduction in

60 degrees, 3. Resist adduction

in 60 degrees

Joint Mobilizations

Pubic Shear Mobilization

SORT

C

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Order of Treatment Procedures

Pubic Lesions

Sacral Lesions (SI)

Innominate Lesions (IS)

Dynamic Lumbar Stabilization

Function Strengthening / Progression

SORT

C

References

1 Dreyfuss, et al (1996). The value of medical history and physical

examination in diagnosing sacroiliac joint pain. Spine, 21: 2594-2602.

2 Slipman, et al (2000). Sacroiliac joint pain referral zones. Archives of

Physical Medicine & Rehabilitation, 81: 334-338.

3 Schwartzer, et al (1996). The sacroiliac joint in chronic low back pain:

Joint double block and value of sacroiliac provocative tests. Spine, 21:

1889-1892.

4 Riddle & Freburger (2002). Evaluation of the presence of sacroiliac

joint dysfunction using a combination of tests: A multicenter intertester

reliability study. Physical Therapy, 82: 772-781.

5 Potter & Rothstein (1985). Intertester reliability of selected clinical

tests of the sacroiliac joint. Physical Therapy, 65: 1671-1675.

6 Flynn, et al (2002). A clinical prediction rule for classifying patients

with low back pain who demonstrate short-term improvement with

spinal manipulation. Spine, 27: 2835-2843.

References

7 Laslett, et al (2003). Diagnosing painful sacroiliac joints: A validity study of McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy, 49: 89-97.

8 Laslett & Williams (1994). The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine, 19: 1243-1249.

9 Cibulka & Koldehoff (1999). The clinical usefulness of a cluster of tests for sacroiliac joint dysfunction in patients with and without low back pain. JOSPT, 29: 83-89.

10 Levangie (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 Therapy, 79: 1043-1057.

11 Scifers (2008). Special Tests for Neurologic Examination. SLACK Inc., Thorofare, NJ.

12 Vincent-Smith & Gibbons (1999). Inter-examiner and intra-examiner reliability of the standing flexion test. Manual Therapy, 4: 87-93.

13 Toussaint, et al (1999). Sacroiliac dysfunction in construction workers. Journal of Manipulative Physical Therapy, 22: 134-139.

14 Toussaint, et al (1999). Sacroiliac joint diagnosis in the Hamburg construction workers study. Journal of Manipulative Physical Therapy, 22: 139-143.

References

15 Carmichael (1987). Inter- and intra-examiner reliability of palpation for sacroiliac joint dysfunction. Journal of Manipulative Physical Therapy, 10: 164-171.

16 Meijne, et al (1999). Intraexaminer and interexaminer reliability of the Gillet test. Journal of Manipulative Physical Therapy, 22: 4-9.

17 Herzog, et al (1989). Reliability of motion palpation procedures to detect sacroiliac joint fixations. Journal of Manipulative Physical Therapy, 12: 86-92.

18 Broadhurst & Bond (1998). Pain provocation tests for the assessment of sacroiliac joint dysfunction. Journal of Spinal Disorders, 11: 341-345.

19 Blower & Griffin (1984). Clinical sacroiliac tests in ankylosing spondylitis and other causes of low back pain – 2 studies. Annuals of Rheumatoid Disorders, 43: 192-195.

20 Russell, et al (1981). Clinical examination of the sacroiliac joints: A prospective study. Arthritis Rheumatology, 24: 1575-1577.

21 Kokmeyer, et al (2002). The reliability of multi-test regimens with sacroiliac pain provocation tests. Journal of Manipulative Physical Therapy, 25: 42-48.

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