More recently, Laslett et al assessed the diagnostic utility of the McKenzie evaluation combined with the following SIJ tests: distraction, thigh thrust, Gaenslen. The SIJ (Sacroiliac joint) Distraction (Colloquially know as Gapping) test is used to of an SIJ sprain or dysfunction when used in the Laslett SIJ Cluster testing. (Laslett et al., ). Conceptually, it seems reasonable to propose that stress testing of the SIJ should provoke pain of SIJ origin. However, clinical stress tests .
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The sacroilliac joint, or SI joint, is one of those challenging areas of the body that we all have to deal with from time to time. Many of the commonly performed assessments for SI joint pain seemed to not be very reliable and sometimes not even valid.
So treatment almost sometimes became taking a shot in the dark as I never truely felt confident in my exam findings. This led me to perform treatments and progressions of patients based on trial and error rather than because of exam findings.
Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint
Treating this way, to me, is a huge pet peeve, so I started to research the area to gain more comfort in my SI joint examination. I found some interesting research regarding palpation, SI joint motion, and provocative testing. Here are some of the things that I found along that way that really helped me get better at diagnosing SI joint pain, hope it helps you too. One of the simplest methods of assess the SI joint is palpation.
However, the reliability and validity of palpating the SI joint has come into question in recent years. It is an interesting paper, that certainly makes you think. In the paper, the author describes the several layers of tissue that sit between the skin and the posterior SI joint, which is cm deep to the skin, and the inherent challenge of both reliability and validity of palpating something so deep.
Assessing the amount of SI joint motion lasletf the symmetry of the SI joint itself is a very commonly performed technique during SI joint examination. This method of examining the SI laspett is popular and accepted, despite the lack of research supporting the technique.
Based on the above information regarding palpating the SI joint, one would question the si to palpate AND now accurately assess motion in addition. If palpation has poor reliability, this automatically makes assessing motion difficult. They found poor inter-tester reliability, low sensitivity, and low specificity in several commonly performed laaslett. This is a particularly interesting dij to read if you have interest in this area.
Another study from Robinson et al had similar conclusions, stating that SI joint motion palpation tests have poor inter-tester reliability. Thus it appears that the reliability and validity of assessing Lalsett joint symmetry and motion may be too poor to be used clinically.
The amount of lasllett of the SI joint motion is extremely small, perhaps less than 2mm and 2 degrees of translation and rotation. This makes detecting patholgoical movement extremely challenging.
However, I still think symmetry and motion assessment may be a valuable component of the SI joint examination in the case of significant malalignment and pathology, and still should be assessed. Van der Wurf et al published an interesting study looking at the location of symptoms reported in patients with SI joint pain and dysfunction. The authors found that:.
However, by performing several tests together, you can increase your sensitivity and specificity of detecting SI joint dysfunction. Combining the two studies, there are 5 provocative tests to perform when attempting to diagnose SI joint pain:. Laslett et al report that the accuracy of detecting SI joint dysfunction is increased with at least 3 of the 5 tests are positive. Furthermore, if all 5 tests are negative, you can likely look at structures other that the SI joint.
Interestingly, another study by Kokmeyer et al agreed with the previous findings, but also noted that the thigh trust test alone was almost as good at detecting SI joint dysfunction as the entire serious performed together. It seems like performing a series of provactive SI joint tests is better than one true test in isolation, though I would specifically emphasize the thigh thrust test. In my experience, you have to use a decent amount of force during the thigh thrust technique to avoid missing a positive provactive sign.
Great job and thanks for sharing Harrison! These are the tests recommended by the above authors to use together:. I will admit that I am not a SI joint expert, so I am interested in hearing the opinion of my readers that deal with a lot of SI joint dysfunction.
Based on some of the research above, we should all consider the location of symptoms and a series of provocative testing when attempting assessing the sacroilliac joint and diagnosis SI joint pain and dysfunction. He stated that 3 out of 4 provocation tests distraction, compression, thigh thrust or sacral thrust demonstrated a sensitivity of.
But like you showed with this article, using a cluster of diagnostic provocation tests will increase our likelihood of differentiating the SIJ from other parts of the body we should also rule out the lumbar spine and hip prior to assessing the SI joint …Nice post. Thanks for the post Mike. I still find it interesting that there is no agreement whether the SIJ even moves after adolescence besides during child birth and when relaxin is circulating.
I recently took a Sahrmann course and asked her on the side about SIJ dysfunction. This test helps differentiate asymmetrical bony landmarks. By slowly ramping up force, you will either feel a smooth glide or an abrupt stop prematurely. That is then considered the dysfunctional side. Which side is dysfunctional??! Always good to read your stuff and see what you find interesting out there.
Thanks for the link back to videos Mike! Good research is out on a very difficult region. Great information as always!
When looking at the sacrum you always have to look at L5 as well. They should move inverse laxlett one another. The sacrum also can have torsion problems which can create unilateral leg pain with standing or sitting.
The Jones Institute for SCS does a excellent job in teaching this as well as instructing clinicians in evaluating this and providing simple manual treatments which restore this inverse relationship. Then work on the asymmetry found in the reminder of your examination. If I cannot decrease the symptoms with one of these mobilizations, I have to seriously question whether SI path is the problem.
The joys of the SIJ and pelvic girdle never cease. Thanks for the post and starting the discussion. We must use the appropriate language so that our clinial reasoning and professional conversations within the health care community can be more accurate.
Dysfunction can indicate hypomobility, hypermobility or poor movement patterns about the joint. We MUST speak the same language. A continued hot topic is classification of low back pain. Non specific low back pain studies are not very helpful as there are many flavors of dysfunction, we all know that. The SIJ is joint that moves, transmits forces a lot of them and has muscle and fascial connections, and is ultimately controlled by the CNS.
You may have a frozen shoulder that leads to neck pain. Just like a stiff SIJ can lead to back or hip pain, etc. So any dysfunctional movement pattern can lead to poor force transmission.
Assessing the Sacroiliac Joint: The Best Tests for SI Joint Pain – Mike Reinold
This may by associated with a poor movement pattern, or simply may not transmit loads effectively. Remember the density of the interosseous liagment. It is a tremendous force transducer. If it is lax, how does this affect the lumbopelvic-hip complex?
Sacroiliac Distraction Test
All 3 above could be a cause of pain. As could an infection. There are over different types of infections that can lead to sacroilitis. We cannot forget that. Salmonella is one relatively common one.
The problem is, you usually have some type of combination of the above. Einstein said to keep things as simple as possible, but no simpler. In this case, classifying the SIJ as painful or not painful is very helpful.
But this is just too simple. We must then attempt to classify and or subclassify further. Inwe have a long way to go. But a good place to start your journey is with the current concepts published by the Orthopedic section of the APTA. I am not sure classifying further is appropriate given what we know about the motion at the SIJ and the asymmetry in anatomy and movement that exists in non-painful, non-dysfunctional individuals. Lastly any classification or testing shoulder should assist in guiding treatment target or intervention components as well as result in superior outcomes.
If not, we are classifying for the sake of classifying EVEN if that classifying is reliable. In addition, we discuss some of the issues here:. I appreciate your thoughtful reply on this blog as well as your response to Manual Therapy journal in response to the Adahi et. I agree, motion testing and symmetry assessment has serious validity and reliability concerns.
In a study, we found skj we still do not have a reliable way of assessing ankle dorsiflexion with a goniometer. But I still use this technique as it provides clinical utility for me. I attempt to carefully control variables such as force, subtalar position, and patient assitance in order to improve my intra-rater reliability.
Sacroiliac Joint Special Test Cluster
I also keep in mind the potential weakness and bias I may have with my measurement and rely on other clues to indicate a functional loss of dorsiflexion. I correlate this with gait analysis, squat performance, patterns of compensation in the midfoot, etc. If lazlett patient self regulates their stride length or compensates well through the midfoot or elsewhere, this dysfunction could go on for years painfree.
Just because a patient is painfree does not mean that they have serious issues with transmitting forces. However, this approach neglects some important points. lasletf
There are conditions that clearly lead to SIJ hypomobility, which can be validated with diagnostic imaging such as ankylosing spondylitis. Finally, the knowledge of pain by itself is helpful but can be dangerous if treatment paradigms are designed based on this.
What if the patient has an infection, or a stress fracture? Good therapists are classifying already whether they know it or not.