Sacroiliac Joint N Ischium N Ilium N Pubis James R

Pelvic Anatomy

Evidence-Based Evaluation & Treatment n Innominates of the Sacroiliac Joint n ischium n ilium n pubis James R. Scifers, DScPT, LAT, ATC Moravian College n Sacrum Athletic Training Program

Articulations Biomechanics of the Pelvis

n Function of the SI Joint n transmit vertical forces n Sacroiliac Joints n transmit ground n Pubic Symphysis reaction forces n Lumbo-Sacral Joint

Sacral Motions Arthrokinematics of the SI Joint

n During trunk flexion… n Sacral Base (S1) n Initially, sacral flexion occurs (base of sacrum n Sacral Apex (S5) moves anterior) n Flexion (nutation) n Later, sacral extension occurs with continued trunk flexion (base of sacrum moves posterior) n occurs during exhalation n Extension (counternutation) n occurs during inhalation

1 Dysfunction Classification Ilio-Sacral (IS) Dysfunctions

n Sacroiliac Joint (SIJ) n Named for motion at n Any injury to SIJ PSIS n Ilio-Sacral (IS) n anterior rotation n ilium (innominate) n posterior rotation moving on sacrum n up-slip n Sacro-Iliac (SI) n down-slip (rare) n sacrum moving on ilium n in-flare n Pubic Shear n out-flare n Pubic symphysis / Pubic shear lesion

Sacro-Iliac (SI) Dysfunctions Pubic Shear Lesions

n Sacral Rotations n Named for “direction facing on axis” n Named for any movement at pubic n Forward Rotations symphysis n right on right n Indicates injury to pubic n left on left symphysis n Backward Rotations n right on left n left on right

SI Evaluation Evidence-Based Practice (EBP)

n Reliability (k) is reproducibility of test results, can be n History* intra-tester (within one clinician) or inter-tester (between n Observation** multiple clinicians) n Palpation** n Sensitivity (sens) is the ability of test to RULE OUT a condition. The higher the sensitivity, the greater n AROM / PROM chance that a NEGATIVE test means the condition is n MMT absent n Special Tests* n High sensitivity + negative test = rule condition out (SnNout) n Neurologic Exam n 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 n High specificity + positive test = rule condition in (SpPin)

2 Evidence-Based Practice (EBP) Strength of Recommendation Taxonomy (SORT)

n Positive Likelihood Ratio (+LR) indicates the likelihood that a POSITIVE test means the condition is SOR T C at egory Level of Evidence present SORT Consistent, good-quality, patient-oriented evidence n Negative Likelihood Ratio (-LR) indicates the A likelihood that a NEGATIVE test means the condition is absent SORT Inconsist ent or limit ed-quality, patient-oriented evidence B

SORT Consensus, disease-oriented evidence, C usual practice, expert opinion, or case series

History Pain Referral Patterns2-3

n SI pain typically unilateral, may refer n Pain typically localized to involved SI joint Pain Location Fr equency Sensitivity Specificity + LR - LR 1 n Sens = .76, Spec = .47, +LR = 1.4, -LR = 0.51 Lum bar S pine 72% N/A N/A N/A N/A n Pain may increase with trunk rotation, sidegliding, Buttock1 94% 0.80 0.14 0.9 1.42 trunk/hip extension or sidelying Gr oin1 14% 0.19 0.63 0.51 1.29 n MOI may include falling or twisting Thigh 48% N/A N/A N/A N/A n MOI more often insidious (48 hour rule to assess for cause) n Aggravating Activities usually includes sitting Lower Leg 28% N/A N/A N/A N/A n Sens = .03, Spec = .90, +LR = 0.3, -LR = 1.071 Foot 12% N/A N/A N/A N/A

Clinical Application #1: Failure to report pain at the PSIS is a good predictor for patient NOT suffering from SIJ pathology SORT B SORT Clinical Application: Failure to report buttock pain is a Clinical Application #2: Pain increased with sitting is a good good predictor for patient NOT suffering from SIJ pathology indicator that patient may be suffering from SIJ pathology B

Observation4-6 Palpation4-6

n Observe for spasm n Standing: n erector spinae n ASIS n Observe muscle tone n PSIS (k = .13 - .37) n (k = .23 - .41) n gluteals Iliac Crests n Greater Trochanters n Observe symmetry: n Prone: n PSIS n Sacrum n Iliac Crests n Inf Lat Angle of Sacrum (k = .69) n ASIS n Sacral Sulcus (k = .24) n Greater Trochanter n Sacrotuberous Ligament n Pubic Tubercle n Piriformis (or sidelying) n Supine: n Pubic Tubercle

3 Palpation Location of Pain1 Piriformis Palpation

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 Clinical Application: Patients reporting pain in the region of the B PSIS and the groin are likely to be suffering from SIJ pathology

Sacrotuberous Ligament Palpation ASIS Palpation

PSIS Palpation Iliac Crest Palpation

4 Alignment & Symmetry Active / Passive Range of Motion

n Iliac Crest Heights n Greater Trochanter n AROM tested in standing n higher or lower Levels or sitting n PSIS Relationships n higher or lower n PROM tested in supine or n superior-inferi or n Sacral Sulcus Depths prone n medial-lateral n deeper or shallower n Stress at SI Joint: n ASIS Relationships n superior& inferior n Spine flexion 40-60° n Spine extension 20-35° n superior-inferi or n Inferior Lateral Angle of n Spine rotation 3-18° n medial-lateral Sacrum n Spine side glide 15-20° n deeper or shallower n Hip flexion 100-120° Very low inter-tester reliability values (k = .13 - .37) with n Hip extension 0-15° exception of inferior lateral angle of sacrum (k = .69)4-6 SORT Clinical Application: Pain increased with AROM or PROM Hip Extension to end-range can help differentiate SIJ C pathology from Lumbar Spine pathology

Manual Muscle Testing Neurologic Assessment

n As needed (not usually necessary for diagnosis) n Trunk flexion

n Abdominals n Should be normal in n Hip flexion presence of SI dysfunction n Hip abduction n Dermatomes (L1-S2) n Gluteus Medius n Myotomes (L1-S2) n Gluteus Minimus n Hip adduction n Reflexes n Hip extension n Patellar Tendon (L3-L4) n Achilles Tendon (S1-S2) n Knee flexion n Trunk extension

n Br idging

SORT Clinical Application: Pain increased with bridging is often C indicative of SIJ pathology

Special Tests Special Test Literature

Pain Provocation Tests Positional Tests n Provocation Tests have little predictive value in 1 n Straight Leg Raise Test n Trunk Flexion Test isolation or combination n Gaenslen Test n March Test n Inter-tester Reliability of Positional Special Tests is low 6,8 n Thigh Thrust Test n Supine to Sit Test n Positional Special Tests performed in combination n FABER / Patrick’s Test n True LLD Test greatly increase value of findings 7-10, 22-23 n Gapping Test n Apparent LLD Test n Compression Test n Trendelenburg’s Sign n Sacral Spring Test n Thomas Test n SI Rock Test n Flamingo Test SORT Clinical Application: SIJ special tests should always be A used diagnostically in combination & not in isolation

5 Special Test Literature Special Test Literature

n Laslett, et al (2005)23 n Van der Wuff, et al (2006) 22 n 2 of 4 Positive Special Tests n 3 of 5 Positive Special Tests n Thigh Thrust, Distraction, Compression & Sacral n Thigh Thrust, Distraction, Compression, Patrick’s & Spring Gaenslen’s Sens. Spec. + LR - LR Sens. Spec. + LR - LR .88 .78 4.00 0.16 .85 .79 4.02 0.19

n Take Home Message: n Take Home Message: n In combination, tests are good for ruling in and n In combination, tests are good for ruling in and ruling out SIJ dysfunction ruling out SIJ dysfunction

Special Test Literature Special Test Literature

n Laslett, et al (2003)7 n Cibulka & Koldehoff (1999)9 n 3 of 5 Positive Special Tests n 4 of 4 Positive Special Tests, 219 subjects n Thigh Thrust, Distraction, Compression, Gaenslen’s n Standing Flexion, Sitting PSIS Palpation, Supine to & Sacral Spring Sit & Prone Knee Flexion Test Sens. Spec. + LR - LR Sens. Spec. + LR - LR .91 .87 4.16 0.11 .82 .88 6.83 0.20

n Take Home Message: n Take Home Message: n In combination, tests are excellent for ruling in and n In combination, tests are good to excellent for ruling out SIJ dysfunction ruling in and ruling out SIJ dysfunction

Straight Leg Raise Test Gaenslen Test

n Clinician passively flexes n Patient is supine with both hip with knee extended legs extended n Pain at 0-30 degrees---hip n Uninvolved knee is pathology or nerve root brought to chest while n Pain at 30-50 degrees--- involved hip remains in sciatic nerve involvement extension n Limited ROM of less than n Overpressure is applied to 70 degrees---hamstring tightness involved side n Pain at 70-90 degrees--- n Positive test is pain sacroiliac joint involvement indicating SIJ involvement Sensitivity Specificity + LR - LR Sensitivity Specificity + LR - LR 0.78-0.97 0.10-0.57 1.00-1.98 0.05-0.35 0.21-0.71 0.26-0.77 0.75-2.21 0.65-1.12 All data for detecting lumbar disc herniation, not SIJ pathology11 K = .54 - .761, 6, 8, 20-21

6 Thigh Thrust Test FABER or Patrick Test

n Patient is supine n Patient supine with hip positioned in flexion, abduction and external n Involved hip is flexion and rotation adducted n Clinician applies over-pressure at n Posterior shearing force is knee toward table while applied through femur in stabilizing opposite ASIS varying degrees of hip n Positive test is pain indicating SIJ adduction / abduction pathology n Positive test is buttock pain n If patient exhibits a decrease in indicating SIJ involvement pain, an out-flare should be suspected Sensitivity Specificity + LR - LR Sensitivity Specificity + LR - LR 0.36-0.88 0.50-1.00 0.70-2.80 0.20-1.28 0.10-0.77 0.16-1.00 0.41-0.82 0.23-1.94 K = .64 - .881, 6, 8, 18, 21 K = .60 - .621, 6, 21

Gapping or Distraction Test Compression Test

n Patient supine n Patient is positioned in n Clinician applies supine or sidelying crossed-arm outward n Clinician applies medial pressure on the ASIS pressure at iliac crests n Positive test is pain, to compress ASIS indicating SIJ pathology n Positive test is pain n If patient reports relief indicating out-flare of pain, an out-flare n Relief of pain indicates should be considered SIJ pathology

Sensitivity Specificity + LR - LR Sensitivity Specificity + LR - LR 0.55-0.60 0.81-1.00 3.20 0.49 0.60-0.70 0.69-1.00 2.20-7.00 0.33-1.00 K = .26 - .691, 6, 8, 18, 21 K = .26 - .736, 17-20

Trunk Flexion Test Gillet or March Test

n Palpate PSIS bilaterally in n Patient brings knee to sitting or standing chest in either standing or n Painful PSIS is lower sitting n Painful PSIS rises higher n Clinician looks for during flexion downward motion of PSIS n Painful PSIS moves first n Uninvolved side will move and “most” (PSIS heights are equal at conclusion of inferiorly, involved side test) will move less or not at all n Positive test indicates n Positive test indicates posterior rotation posterior rotation Sensitivity Specificity + LR - LR Sensitivity Specificity + LR - LR K = .08 - .68 4-6, 12-14 0.43 0.68 1.3 0.84 N/A N/A N/A N/A Intra-tester K = .02 – .31, Inter-tester K = .02 - .591, 5-6, 15-17

7 Supine to Sit True Leg Length Measurement

n Patient is supine n Patient performs a bridge n Clinician assesses leg length at medial malleoli n Patient is instructed to sit up while applying traction to bilateral lower extremities n Positive findings are a change in leg length n posterior rotation: short to long n anterior rotation: long to short n LLD: long to long or short to short Sensitivity Specificity + LR - LR Measured ASIS to medial or lateral malleolus, K = .19 10 0.44 0.64 1.37 0.88 indicates bony differences between lower extremities

Apparent Leg Length Measurement Trendelenburg’s Sign

n Patient performs SLS n Clinician observes pelvic height from behind patient n Inferior movement of iliac crest on non-stance side indicates weak gluteus medius on stance side n This is an associated sign in presence of out-flare or SIJ pathology positive negative

Measured Umbilicus to medial or lateral malleolus, Sensitivity Specificity + LR - LR indicates innominate rotation N/A N/A N/A N/A

Thomas Test Sacral Thrust or Sacral Springing

n Patient is supine at edge of n Patient is prone table n Clinician applies n Uninvolved knee is passively brought to chest downward pressure to n Positive test is involved lower sacrum extremity demonstrating: n Positive test is pain, n Hip flexion (tight iliopsoas) indicating sacral rotation n Associated finding with anterior rotation n Test can be repeated on n Knee extension (tight RF) four corners of sacrum n Associated finding with anterior rotation n Hip abduction (tight ITB/TFL) n Associated finding with in-flare Sensitivity Specificity + LR - LR Sensitivity Specificity + LR - LR 0.27-0.75 0.29-1.00 0.75-3.00 0.50-1.62 N/A N/A N/A N/A K = .30 - .561, 6, 17-18, 20

8 SI Rock Test Flamingo Test

n Patient is supine n SLS causes or increases n Clinician passively brings involved knee to opposite pain on involved side--- shoulder (combination of may also include buttock hip flexion and internal pain rotation) and applies n Patient may be asked to overpressure hop on one leg to n Positive test is buttock pain increase or cause pain n Indicating involvement of n Positive test is indicative sacrotuberous ligament of SIJ pathology OR n left on right rotation pubic shear lesion n right on left rotation Sensitivity Specificity + LR - LR Sensitivity Specificity + LR - LR N/A N/A N/A N/A N/A N/A N/A N/A

Special Test Take-Home Points Special Test Take-Home Points

n Perform special tests in combination to improve diagnostic accuracy SORT n Best test for ruling-in an outflare is the Compression Test A SORT B n Best tests for ruling-in SIJ pathology are FABER, Thigh Thrust, Gaens len & Gapping Tests SORT B n Best test for ruling-in an SI Dysfunction is the Sacral Spring Test SORT n Best test for ruling-out SIJ pathology is Thigh Thrust Test B SORT B n Best test for ruling-in a pubic shear lesion is the Flamingo Test SORT n Best tests for ruling-in posterior rotation are March & C Supine to Sit Tests SORT C

Treatment Strategies Movement / Resistance Key

n Muscle Energy n Isometric Patient Generated Force Techniques n Clinician Generated Force n Joint Mobilization Techniques n Stretching Techniques n Strengthening Techniques n Dynamic Lumbar Stabilization

9 SORT SORT Anterior Rotation C Posterior Rotation C

n Problem List? n Problem List? n MET n MET n Hamstrings n Quadric eps n Joint Mobilizations n Joint Mobilizations n Posterior Mobilization n Anterior Mobilization n Stretching n Stretching n Rectus Femoris & Hip n Hamstrings Flexors n Strengthening n Strengthening n Quadric eps & Core n Hamstrings & Core Also may use Scissoring or Arm Break to treat anterior or posterior Also may use Scissoring or Arm Break to treat anterior or posterior rotation rotation

SORT SORT Upslip C In-flare C

n Typically secondary to n Problem List? trauma n MET n Problem List? n Adductors n MET n Joint Mobilizations n None n Out-flare Mobilization n Joint Mobilizations (forced hip adduction n Inferior Glide / Long Axis with flexion…SI Rock Distraction Test) n Stretching n Stretching n None n ITB & TFL n Strengthening n Strengthening n None 5 degrees hip flexion, 30 degrees hip abduction with hip ER or hip IR n Adductors & Core

SORT Alternate In-flare MET Out-flare C

n Problem List? n MET n Abductors n Joint Mobilizations n In-flare Mobilization (force hip abduction with ER…FABER Test) n Stretching n Adductors n Strengthening n Gluteus Medius / Minimus & Core

10 SORT Out-flare Mobilization Right on Right Sacrum C

n Problem List? n MET n None n Joint Mobilizations n Sacral Springing on inferior right angle of sacrum n Other n Stretch / Treat Right Piriformis & Strengthen Core

SORT SORT Left on Left Sacrum C Right on Left Sacrum C n Problem List? n Problem List? n MET n MET n None n None n Joint Mobilizations n Joint Mobilizations n Sacral Springing on n Sacral Springing on inferior left angle of superior right angle of sacrum sacrum n Other n Other n Stretch / Treat Left n Address left STL pain Piriformis & & Strengthen Core Strengthen Core

SORT Left on Right Sacrum C Sacral Mobilizations n Problem List? n MET n None n Joint Mobilizations n Sacral Springing on superior left angle of sacrum n Other n Address right STL pain & Strengthen Core

11 Order of Treatment Procedures References

n 1 Dreyfuss, et al (1996). The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine, 21: 2594-2602. n Pubic Lesions n 2 Slipman, et al (2000). Sacroiliac joint pain referral zones. Archives of Physical Medicine & Rehabilitation, 81: 334-338. n Sacral Lesions (SI) n 3 Schwartzer, et al (1996). The sacroiliac joint in chronic low back pain: Joint double block and value of sacroiliac provocative tests. Spine, 21: n Innominate Lesions (IS) 1889-1892. n Dynamic Lumbar Stabilization n 4 Riddle & Freburger (2002). Evaluation of the presence of sacroiliac joint dysfunction using a combination of tests: A multicenter intertester n Function Strengthening / Progression reliability study. Physical Therapy, 82: 772-781. n 5 Potter & Rothstein (1985). Intertester reliability of selected clinical tests of the sacroiliac joint. Physical Therapy, 65: 1671-1675. n 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. SORT C

References References

n 7 Laslett, et al (2003). Diagnosing painful sacroiliac joints: A validity n 15 Carmichael (1987). Inter- and intra-examiner reliability of palpation study of McKenzie evaluation and sacroiliac provocation tests. for sacroiliac joint dysfunction. Journal of Manipulative Physical Australian Journal of Physiotherapy, 49: 89-97. Therapy, 10: 164-171. n 8 Laslett & Williams (1994). The reliability of selected pain provocation n 16 Meijne, et al (1999). Intraexaminer and interexaminer reliability of tests for sacroiliac joint pathology. Spine, 19: 1243-1249. the Gillet test. Journal of Manipulative Physical Therapy, 22: 4-9. n 9 Cibulka & Koldehoff (1999). The clinical usefulness of a cluster of n 17 Herzog, et al (1989). Reliability of motion palpation procedures to tests for sacroiliac joint dysfunction in patients with and without low detect sacroiliac joint fixations. Journal of Manipulative Physical back pain. JOSPT, 29: 83-89. Therapy, 12: 86-92. n 10 Levangie (1999). Four clinical tests of sacroiliac joint dysfunction: n 18 Broadhurst & Bond (1998). Pain provocation tests for the The association of test results with innominate torsion among patients assessment of sacroiliac joint dysfunction. Journal of Spinal Disorders, with and without low back pain. Physical Therapy, 79: 1043-1057. 11: 341-345. n 11 Scifers (2008). Special Tests for Neurologic Examination. SLACK n 19 Blower & Griffin (1984). Clinical sacroiliac tests in ankylosing Inc., Thorofare, NJ. spondylitis and other causes of low back pain – 2 studies. Annuals of n 12 Vincent-Smith & Gibbons (1999). Inter-examiner and intra-examiner Rheumatoid Disorders, 43: 192-195. reliability of the standing flexion test. Manual Therapy, 4: 87-93. n 13 Toussaint, et al (1999). Sacroiliac dysfunction in construction workers. Journal of Manipulative Physical Therapy, 22: 134-139. n 14 Toussaint, et al (1999). Sacroiliac joint diagnosis in the Hamburg construction workers study. Journal of Manipulative Physical Therapy, 22: 139-143.

References Questions?

n 20 Russell, et al (1981). Clinical examination of the sacroiliac joints: A prospective study. Arthritis Rheumatology, 24: 1575-1577. n 21 Kokmeyer, et al (2002). The reliability of multi-test regimens with sacroiliac pain provocation tests. Journal of Manipulative Physical Therapy, 25: 42-48. n 22 Van der Wuff, et al (2006). A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Archives of Physical Medicine & Rehabilitation, 87: 10-14. n 23 Laslett, et al. Diagnosis of sacroiliac joint pain: Validity of individual provocation tests and composites of tests. ManualTherapy, 10: 207- 218.