The last post on this site discussed how we can move forward as a profession. Over the next several months, I intend to further this discussion with several topics which I believe we need to address head on. Today’s topic: SI Joint palpatory/movement tests
When I was in Physical Therapy school, I learned the whole slue of SI joint dysfunction tests. I was never too sure I was right with my findings and couldn’t understand why I didn’t see what my clinical instructors would see. As I became more experienced, I came to the conclusion that these tests were merely bogus.
So my FIRST recommendation, in this series which I am calling “A few tests to toss”, is to throw away the sacroiliac palpatory/movement tests and replace them with provocation tests.
Physical Therapists (along with Physicians and Chiros) have spent alot of time educating each other, as well as patients, on abnormal mechanics of the sacroiliac joint. We have found one leg to be longer than the other, one iliac crest to be higher than the other and then provided an intervention which has supposedly corrected this. Well, let me be the first to recommend…STOP. Literature indicates that our palpatory abilities are poor and the ability to find abnormal mechanics of the sacroiliac joint is an illusionary fantasy with little scientific backing. We likely “see what we want to see”. Pre-examination bias occurs from our subjective examination in combination with prior experience.
It all comes down to inter-rater reliability and poor diagnostic accuracy:
Inter-rater reliability is essentially the ability for multiple practitioners to come to the same diagnostic conclusion regarding an issue. ie. If you have multiple individuals perform the same test, the results should be the same.
Palpatory and movement tests of the SI joint have extremely low inter-rater reliability. Evidence indicates that we are unable to reliably detect side-to-side differences and greater experience actually reduces reliability (yes, novices appear to be more accurate—likely by chance).
So, throw out:
The Gillet Test, Seated Flexion Test, Standing Flexion Test, Prone Knee Flexion and Long-sitting Test. Cibulka did report high sensitivity and specificity values for these tests when clustered but:
1. his study did not use an appropriate reference standard (ie. the presence or absence of low back pain)
2. there was inadequate blinding
3. his study lacked face validity due to using a cluster of individually unreliably tests
i.e. The one study that showed promise of these tests was poorly constructed.
I recommend we use…Provocation SIJ Tests
For all provocation tests, a positive test is the reproduction of symptoms and negative test is no reproduction of symptoms.
1. Distraction Test: The patient is supine the examiner applies pressure to “spread” the ASISs.
2. Compression Test: The patient is in a side-lying position. The tester is behind the patient with both hands applying a downward pressure through the anterior portion of the ilum, spreading the SIJ.
3. Thigh Thrust Test:The patient is supine and the hip is flexed to 90 degrees and the knee is bent. The tester then applies a posterior shearing force to the SIJ through the femur. Avoid excessively adducting during this exam.
4. Gaenslen’s Test (Right & Left): The patient is supine lying near the side of table. The examiner stands on side of patients and places leg closest to them off edge of table. The examiner then instructs the patients to actively flex the opposite leg to their chest and hold. The examiner then applies pressure to the leg handing off edge of table forcing the hip into extension.
5. Sacral Thrust Test: The patient is prone and the examiner applies an anterior pressure through the sacrum.
2 out of 4 provocation tests (distraction, compression, thigh thrust or sacral thrust) have sensitivity of .88 and specificity of .78. + Likelihood ratio (LR) of 4.00 and – LR of .16 for SIJ pathology.
3 out of all 6 provocation have sensitivity of .94 and specificity of .78. + LR of 4.29 and – LR of .80 for SIJ pathology.
The take home message: We can provoke pain in the region of the sacroiliac joint but we cannot identify biomechanical issues that would lead to that pain.
Below is a video of the tests performed:
Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of Sacroiliac Joint Pain: Validity of Individual Tests and Composites of Tests. Manual Therapy. 2005: 10; 207-18.
van der Wurff P, Hagmeijer RH, Meyne W. Clinical tests of the sacroiliac joint: A systematic methodological review. Part 1: Reliability. Man Ther. 2000;5:30–36.
Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S, Telje T. The reliability of selected motion and pain provocation tests for the sacroiliac joint. Man Ther. 2007;12:72–79.
Herzog W, Read LJ, Conway PJ, Shaw LD, McEwen DC. Reliability of motion palpation procedures to detect sacroiliac joint fixations. J Manipulative Physiol Ther. 1989;12:86–92.
Cibulka MT, Koldehoff R. Clinical usefulness of a cluster of sacroiliac joint tests in patients with and without low back pain. J Orthop Sports Phys Ther. 1999;29:83–99.