"A few tests to toss"…Part 1

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.

Distraction Test
1. Distraction Test: The patient is supine the examiner applies pressure to “spread” the ASISs.

Compression Test
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.

Thigh Thrust
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.

Gaenslens Test
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.

Sacral Thrust
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:
[youtube=http://www.youtube.com/watch?v=ukDJ_OxOuBY] Citations:
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.


All Comments

  • I would agree with this notion of getting rid of the SIJ palpatory/movement tests. Laslett’s study was well constructed and provides a solid method of identifying SIJ pathology. Remember that these are provocative tests and should be treated as such. PROVIDE AMPLE FORCE DURING THESE TESTS! Great post Joseph.

    Alden Taylor August 14, 2012 11:38 pm Reply
  • Very well written article. I’m in the manual therapy syllabus of courses held by the CPA and they are dogmatic about PIVM and PAVIM testing… I fight with the question of how can a whole generation of great manual therapists be essentially bull$hitting their clinical findings when examining their clients. Or, is it that deep down they know they don’t really know what they feel but have to cling to something to guide their clinical practice…

    jessephysio August 15, 2012 12:05 am Reply
  • This is great info and yes I have been working with provocation tests instead of palpatory. Mostly because of the research. But what about Vleeming’s Active SLR in combination with these?

    Jacob August 15, 2012 5:58 am Reply
  • Nice post! Unfortunately, the palpatory tests are still taught in school, as I just graduated. We saw the (Laslett, I think) article on the provocation tests, though, and it seemed like the palpatory tests weren’t really emphasized, at least. Is the next target palpatory testing for spinal rotations?

    Erik August 15, 2012 11:04 am Reply
    • Haha. Yea there is no reliability in detecting FRS/ERS dysfunctions either. I plan to debunk or at least address some of these issues over the next year. Anyone interest in assisting??? I always welcome guest posts…

      josephbrence August 15, 2012 11:07 am
    • If you’re interetsed, I would be happy to do a guest post regarding manual therapy examination and their reliability etc
      Feel free to read my blog to see if you’d be interested in a guest post

      Jessephysio August 15, 2012 12:58 pm
  • Great post. We really need to get away from
    these tests. But if we take a good look at our testing procedures and their meaning, should we settle for 4-5 LH ? Is it good enough ?

    Nirit August 15, 2012 12:04 pm Reply
  • Jessephysio,
    I am interested. Email it to Joseph.brence@physiocorp.com . My rule: evidence-based and include citations

    josephbrence August 15, 2012 2:33 pm Reply
  • Great comment Joe. The CPA syllabus is making some slow progress to steer away from the palpatory SI tests but despite this, they still heavily rely on notions of SI dysfonctions “à la” Diane Lee with force closure and compression dysfonctions that, they think, is still amenable to SI joint manips and complicated isolated motor retraining of the pelvic and hip muscles. And the number of patients coming in telling me they had to have their SI ajusted by some other therapist because it was out of place is still considerable…

    Frédéric Wellens, pht, Canadian Intermediate Diploma in Manual Therapy August 15, 2012 5:27 pm Reply
  • Joe
    Love evidence based stuff and “MYTH BUSTING”. My interest and research focus is in balance and fall risk
    assessment in Active Older Adults. I have written articles in Advance and have published in JGPT-Sprin
    Scale Test. Perhaps we can bust myths and provide evidence on several fronts on various issues.

    Louis DePasquale PT MA August 15, 2012 8:52 pm Reply
    • Sure. Would love to add some guest posts, just send them to joseph.brence@physiocorp.com . Before I post anything, I will do a lit review myself to make sure we are posting good stuff. Much appreciated and looking forward to getting some posts up!!!

      josephbrence August 15, 2012 8:58 pm
  • Thank you for the great post. I really appreciateyour effortt.
    But I do not really agree with your take home message: “We can provoke pain in the region of the sacroiliac joint “. Wht’s the reason to provoke pain around that region?? To diagnose the SI as the “source” or “the “cause” or what your opinion is”………As phyios we can always provoke what we want to find I cannot really understand why we need to do “provocative” tests….
    Secondly, I can see you really appreciate “Neuromatrix”. In my view, whenever doing the tests, I think apart fromwhatever the research has suggested…..how about the context, the therapist’s explanation about the test, the patient’s belief system…….go on…..
    From these 2 simple questions in my mind, I would suggest we would throw out the provocative tests as well.
    Any thoughts???

    hsieh-Hsing August 15, 2012 9:20 pm Reply
    • I believe you have taken the take home message out of context. I stated “We can provoke pain in the region of the sacroiliac joint but we cannot identify biomechanical issues that would lead to that pain.”
      PTs in the United States are taught multiple ways at assessing SI joint pain. My argument is that we cannot determine biomechanical abnormalities of the SI joint but we are able to provoke pain in the region of the joint, if a person has a suspected issue at the SI joint. Many PTs still believe they can determine innominate rotations.
      In terms of the literature, we know that we can cause pain the region, when the person has possible damage in the region. I suspect this occurs when a person’s brain suspects the threat of tissue damage.

      josephbrence August 15, 2012 9:32 pm
  • So, if the provocation tests are negative, are we to ignore treatment of the SI joint? I thought some of the other tests “thrown out” were to help determine SI joint dysfunction that causes pain ELSEWHERE. Ie- we don’t always do the SI joint tests to determine if there is injury to the SI joint. We can have have dysfunction with NO pain.
    I’m a little confused. I would think the Provocation tests and the SI joint dysfunction tests are testing two different things, or the tests have two different purposes.
    I apologize if I’m misunderstanding the message, too. I’m happy to hear your thoughts.

    Jess August 15, 2012 10:46 pm Reply
    • Hey Jess,
      The diagnostic accuracy of the movement/palpatory SI joint tests I discussed is extremely low (reliability between examiners is less than a 50/50 chance—yes , literature has indicated statistically that two people guessing is more accurate than two people palpating and determining dysfunction in this region—and experience actually decreases agreement).
      There is only 2-5mm of movement at the SI joint and determining that a dysfunction is related to the joint biomechanics is impossible. There is no gold reference standard to confirm one if you believe one exists (ie. you will not see pelvic rotations on xray/CT/MRI etc).
      The only reliable information we can gather from the SI joint is whether or not we can reproduce the patients chief complaint. If we do the provocation tests and they elicit the chief complaint, the pain is likely related to tissues in that region. We are unable to determine anterior/posterior innominate rotations, elevated iliac crest heights, etc.

      josephbrence August 15, 2012 11:00 pm
    • “‘We’ are unable to determine anterior/posterior innominate rotations, elevated iliac crest heights, etc.”
      Disagree: maybe in the research, but if you ONLY do what the research says, you aren’t doing much. There just isn’t enough out there, and too hard to adequately control groups etc. On a DAILY basis, I find a pelvic asymmetry (elevated crest height, innominate rotation): address it with mobilization, progressive stretch and/or MET: immediate increase in strength, flexibility, and movement patterns: THAT ARE LASTING. You throw out your “palpation tests” if you want to, but you are doing your patients an injustice by leaving them asymmetrical and dysfunctional. You have to RESET your patient before you can then Reinforce and Reload them. What does your provocation tests have to do with your corrective interventions? Try assessing and treating function, NOT PAIN. I appreciate you pointing out that intertester/therapist reliability is not high, but don’t throw out the baby with the bathwater. Many of the things we do in medical field do not have high interrater reliability. I see people in my clinic all the time whom have attended PT elsewhere, and made improvements just based on natural healing: no resolution, simply because the PT didn’t take the time to do a good physical exam, consider that the asymmetrical alignment was causing loads of inefficiency and abnormal stress, and thus try to fix that asymmetry prior to loading them up with a bunch of strengthening exercises. You have to do better than just treating pain.

      Andy August 23, 2012 10:36 pm
  • Great post Joe!!
    Jason Silvernail and Myself wrote a letter to the editor of manual therapy on the topic. A blog post on the topic can be found here: http://ptthinktank.com/2012/03/18/si-joint-mechanics-in-manual-therapy-relevance-please/
    Also, great discussion at Mike Reinold’s blog about this topic: http://www.mikereinold.com/2012/03/assessing-the-sacroiliac-joint-the-best-tests-for-si-joint-pain.html

    kridgeway August 15, 2012 11:12 pm Reply
  • Great post. If you add in testing for centralization that improves the accuracy of the diagnostic tests. (The presence of centralization decreases the likelihood that the patient would respond positively to an SIJ injection.)
    I agree with Alden’s point about being certain to apply enough force during the testing. When I took a course with Mark Laslett he also emphasized not starting off with too much force on the tests. If a patient has a hot joint and the first test is too painful, they may be reluctant to go through the remainder of the tests. (I perform them with progressively increasing force.)

    Paul Weiss August 16, 2012 4:56 pm Reply
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  • Hi Joseph. Great blog, it’s about time that we have an open discussion regarding palpatory findings in determining pelvic dysfunctions & I agree that the classic ‘oseopathic model’ as I call it is in need of updating. Certainly the evidence shows that manipluation does not alter the position of the SIJ (Tullberg et al 1998) and numerous studies question the validity & reliability of SIJ motion testing. I was previously an adherent to this model but have for several years questioned it based on the evidence out there and no longer teach palpatory assessment of the SIJ/pelvis on my courses however I do have some issues regarding some of the comments I’ve seen.
    I would like anyone to explain to me what happens after the pain provocation tests tell you ‘something’ about the SIJ. What happens once you have performed your guided corticosteroid injection and reduced pain symptoms surely some rehab follows & isn’t this based on motor control patterns of which there are volumes of work (Vleeming, Lee, Sharman, Hungerford, O’Sullivan only to mention a few). I have read the research by Laslett et al but still struggle with this approach, why such a pain focus and why not instead focus on function; which is what the form-force closure model tries to explain and provide a treatment pathway.
    I disagree that we do not have current biomechanical evidence to support models of pelvic stability, the field of knowledge has been growing in recent years and views that say the form-force closure model is underpinned by a certain biomechanical rules that are not substantiated I think is misleading & a mis-representation of a conceptual model that aims to bring together the current knowledge under the main 4 headings (form closure, force closure, mtor control & emotions). It does not rely on predicting what the biomechanical movements may be instead it aims to explain the shear preventing system better known as the self-bracing mechanism & works with the current knowledge of anatomy & biomechanics available to us. One can certainly take issue with palpation &/or motion testing but this conceptual model is supported by volumes of research & I have to see any evidence to the contrary (happy to be pointed in the right direction).
    Back to my opening comments, we definitely need more open and critical discussion as we to need to have the courage to face up to the mountains of evidence because there are still therapists clinging to an approach which has no basis in the current evidence and continue to propogate patients comments of ‘I was told my pelvis is out of alignment!’
    – Looking forward to your updated blogs.

    Taso Lambridis August 17, 2012 7:34 pm Reply
  • The SIJ still has some secrets to reveal. I had the privelege to evaluate the first H1N1 virus patient a fews post infection. He is a practicing PT. His SIJ is fused on one side and any and all manner of passive motion testing on that side feels like a block of granite, whereas on the other side, it is mobile. No, we most like cannot isolate movement only in the SIJ but we can perceive movement occurring through the SIJ as a fluroscopy study elegantly demonstrated such in 1992. What I found to be rather remarkable is the on the side of the pathologically fused SIJ there was a complete absence of side to side glide of the pelvis tested passively, yet no hint thereof from looking at spinal side bending and hip ROM. There are times when there is a biomechanical dysfunction of the pelvis and at times of the pelvic joint (3 joints collectively can have 3x more motion than just one) in the absence of provoked pain. So I choose to treat dysfunction even in the absence of provoked pain particularly as there are reflex effects elsewhere in the body. I presented 3 case studies at the World Congress on LBP & Pelvic Pain in 20101 on that topic. As an educator I feel a strong responsibility to do a better job of teaching palpation and passive motion testing and of provocation testing. They can be adjusted for individual body types to better isolate forces netting at the region of the posterior SIJ ligaments. Murakami did a remarkable study that brings to question the concept of a “gold standard” of SIJ injection. Best Regards, Jerry Hesch http://www.HeschInstitute.org recently I reinterpreted the biomechanical model of symphysis pubis diastasis which appears not to be a further extension of normative pelvic joint widening but rather takes a very different trajectory at the time of rupture. Relevant because there are women who are wheel chair bound such as in the United Kingdom from surgical diastasis to facilitate “easy delivery.” There is much work to be done, together we can continue to bring the work forward.

    jerry hesch August 20, 2012 11:47 pm Reply
  • This is a great topic, especially since I have been the “spine specialist” in my clinic for years, and I do use a lot of osteopathic techniques. (I never truly got the hang of naming FRS/ERS!) However, joint dysfunction/mobilization is not my primary purpose for using the SIJ palpation tests. I agree that we are not really able to assess joint movement, but I do strongly believe in looking beyond the pain. I had a dislocated pubic symphasis joint (from ski racing accident) for over 2 years before it was diagnosed. The form/force closure model definitely applies when there is a traumatic or repetitive traumatic incident to the pelvis. Muscle slings (http://www.somasimple.com/pdf_files/sijoint_instability.pdf) become critical in this situation, and I have found using the SIJ palpation tests a good screening for the effects of these muscle slings on overall movement dysfunction/instability, not solely to assess the 2-5 mm of motion in the SIJ.
    Recent evidence presented at this year’s APTA conference in Tampa, (by Shirley Sahrmann and others), shows limitations in the hip joint, especially in ext and IR, for ROM and/or strength, result in compensatory patterns in the pelvic girdle. I have been clinically testing this theory with my patients for the past 2-3 years. It is truly amazing how many patients have limits in hip mobility (especially extension), and concurrent complaints of low back/pelvic pain. We have been taught as PTs to compartmentalize the painful joint. This is certainly what is most troubling to the patient in the short-term, but long-term treatment and successful outcomes need to look beyond the painful joint and include the overall movement dysfunction. The painful side is not typically the dysfunctional side. A positive Gillet’s/March test shows more than just movement of the PSIS. The standing leg is often off-balance, and there is also a compensatory shift in the trunk to counter-balance. These are the things I am most looking for with this test. Further provocation and stability tests help better define the patient’s overall movement dysfunction. Even Maitland, who started out as a Rolfer, has leaned more towards “soft tissue unwinding” vs. joint mobilization and manipulation. The chronic effects of the soft tissue dysfunction on combined pelvic girdle/hip function cannot be ignored. Making sense of all the research and putting it all together is challenging. These discussions are very helpful for this purpose. I appreciate all of the great information! Thanks!

    Sue August 23, 2012 5:55 pm Reply
  • I didn’t even realise that people palpated the SIJ motion until I graduated uni. We were taught the *gold standard* of provocation testing, with the addition of the Active Straight Leg Raise. After learning about palpating the SIJs I attempted it briefly but found that conformational bias was too high. Anyway, I’m sure a ‘stiff’ as well as ‘lax’ joint can drive peripheral nociception. Classifying and diagnosing these patients with a biopsychosocial framework is extremely important. Limiting pain around the pelvis region as solely related to SIJ is flawed. Many patients with SIJ related problems also have underlying pelvic floor, sexual dysfunction, stress related pain and their coping strategies to address these issues. Just as the tissues, or brain has sensitised its representation of the SIJ area does not mean that this is the underlying pathology/dysfunction. (now off topic, but it does relate to the provocation testing to guide clinical reasoning) Classification of the further into; Reduced force closure (RFC) and Excessive force closure (EFC) have worked extremely well for me. Simplistically RFC involves low tone (some may say ligamentous laxity), poor lumbopelvic control and pain is improved with increased muscular activation of around the lumbopelvic region (different for every patient), or improvement of symptoms with compression at the ilia (belt, +ASLR) and education. EFC involves high tone, excessive co-contraction of the lumbopelvic musculature causing increased peripheral nociceptive drive from sustained/compressive loading. Patients in this group do well from muscular relaxation, stress reduction, massage, flexibility exercises, diaphragmatic breathing and education of their hypertonic state (NOT for ‘core stabilisation’ – I hate that phrase). Both groups have poor proprioceptive awareness and lumbopelvic dissociative ability and improve with the addition of general exercise (which they likely have ceased in chronic cases). Pelvic floor control and sexual dysfunction are extremely areas to assess in these patients. I cover this briefly with my patients but refer to a women’s health/pelvic floor physio when required. If some of you haven’t read this series of articles, I highly recommend them: http://bodylogi.apexhost.net.au/Content/contentFiles/PDF/Pelvic_Girdle_Pain_-_part_1_2007.pdf http://bodylogi.apexhost.net.au/Content/contentFiles/PDF/Pelvic_Girdle_Pian_-_Part_2.pdf http://bodylogi.apexhost.net.au/Content/contentFiles/PDF/Pelvic_Floor_and_Breathing_in_SIJ_pain.pdf

    Jay August 23, 2012 8:49 pm Reply
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  • Really good points in the main text as well as the comments. As a tenured therapist who still likes to think, I would like to add a few comments, based on 20+ years of experience. The provocation tests are great for identifying primary SI pathology, which in my experience, is pretty rare. I still like to do the March test: not to “diagnose” ilial “rotations”, but as a movement screen. In addition to hip weakness patterns, I often see that one side of the pelvis just moves “funny”, which then makes me look for some sort of muscle imbalance or substitution pattern that causes them to have that hitch. After addressing these imbalances, I still do the adductor squeeze, but find that the pubic sympyhsis pop goes away once balance and proper movement is restored. In contrast to my skepticism regarding ilial rotations, I am not willing to throw out sacral assessments, but I do keep it simple, ala Richard Jackson. In my clinical experience, the sacrum demonstrates stiffness patterns at about the same frequency as I see L4 and L5 movement patterns, and responds beautifully to manipulation (not muscle energy).

    Suzie Freeman August 24, 2012 9:57 am Reply
  • I really like this blog, my compliments to the author for sharing his views and providing a space where physios can discuss Interesting topics, Some nice comments too. However I do disagree we should toss those palpatory tests and replace them with provocation tests.
    Unfortunately, provocation tests do not tell us much a part from pain/no pain. Done in conjunction with other stuff they are great but alone they are useless. Maybe as useless as SIJ palpatory tests by themselves. Not even the side of disfunction provocation tests for SIJ can give you accuratelly, several times we do it on one side and the other hurts or hurts somewhere else. My trouble: is the dysfunction really on the side I am on? Sorry but I am not sure, How can I guarante that by pressing on this side there are no forces going through the joint next door given they are so closely related? Some argue that we can solve this problem by clusting tests but still…what clues a SIJ provocation test gives me torwards a solution? Side of the problem, if so, I guess… just not enough.
    On the other hand, the palpatory stuff may not be very reliable but at least it points me somewhere. Useless or not reliable from reseach point of view when you compare examiners but it does give me a clue of what might be happening and this, together with other information subjectively and objectively obtained, can point me somewhere.
    Now, what I have been doing and intend to keep that way till I find a better one is: SIJ provocation tests clusted with palpatory tests + meningful/functional task – intervention/treatment – re-assessment based on meningful/functional task. If improved great! If not, go back and start again.
    Who cares about re-palpating/re-provoking to see if moves better that way or hurts less when I press it that way as long as we’ve got a smile at the end :-). Patient can do what he/she couldnt do 10min ago…..that will do for me no matter what research A or B says about the reliability of my palpation skills, bad luck for them, because I have not intention to toss something that helps me achieve a positive result in real life not in Wonderland.

    Bruno Rebello August 27, 2012 9:20 am Reply
    • I agree with having the patient to perform a meaningful movement/functional task to assess baseline symptoms/mechanics, performing a treatment, and then repeating the movement/functional task to see if the patient improved as a result of treatment.
      There is a subgroup of low back pain patients whose signs and symptoms are consistent with a painful SI joint. Pain provocation tests are a reliable part of their examination. The results of this examination have been validated when compared to an SI joint injection.
      Unfortunately, to date it would appear that nobody has taken this subgroup and done a randomized, controlled trial to assess which PT treatment(s) they would respond best to. (I do believe that these folks would likely benefit from a program of motor control training, and in some instances SI belting.
      If we are able to identify treatments that this subgroup of low back pain patients respond best to, then we will be able to make better treatment decisions.
      That leads me to ask this to the group: When you have a patient with a positive examination for SI joint pain (by pain provocation testing), what do you do with them based on that information?

      Paul Weiss August 27, 2012 2:33 pm
  • I agree with Andy. I treat pelvic rotations every day with MET’s and I compliment them with stm’s to ilipopsoas and home accupressure techniques, and self stretching of iliopsoas and QL’s while balancing out other postural asymmetries. I have short and long term success with this. I have added techniques over the years but this has netted excellent results for 20 years!
    I have no problem with the provocation tests and use them on occassion. But I don’t treat pain. I listen to it but look for causation and treat that and then look for changes.

    David Gerstel September 14, 2012 1:43 pm Reply
    • #1. Research has determined that we are unable to reliably detect pelvic rotations. And the intrarater reliability is more inconsistent WITH experience (ie. Experience appears to decrease your ability to agree with yourself in regards to what type of rotation you think is occuring. And with vision and tactile changes that occur with aging, if palpable movement tests were reliable, I would suspect age to decrease your ability to reliably detect them. Experience is not a sufficient argument here.)
      #2. There is only 2-5mm of movement at the sacroiliac joint. This is not my opinion. Cibulka and Don Tigney believed rotations occured. But their theories were not supported when tested in clinical trials. The only thing we can reliably do to determine if anything might be occurring at the joint is pain. But we cannot determine what is “causing” the pain. We can only take what we know about “pain neurophysiology” and apply this.
      #3. There is no research to support that joint “asymmetries” are abnormal and cause pain. Postural theories have been deconstructed. For example, an article published in 2000, challenged the concept of lumbopelvic imbalances and pain. The article assessed individuals who had a history of chronic low back pain (CLBP). It assessed the location of pelvic inclination and magnitude of lordosis and found that in individuals with CLBP, there was no more standing lumbar lordosis or pelvic inclination than their counterparts with healthy backs. In patients with CLBP, the magnitude of the lumbar lordosis and pelvic inclination in standing was not associated with the force production of the abdominal muscles. The authors go as far as concluding, “Abdominal muscle strengthening exercises are routinely recommended by physical therapists to correct faulty standing posture in patients with CLBP. These recommendations are often based on assessment of standing posture. We urge physical therapists to avoid prescribing therapeutic exercise programs of muscle strengthening of abdominal muscles in patients with CLBP based solely on assessment of relaxed standing posture.”
      #4. Despite everything I stated above, if you have an approach that works then use it. Just keep in the back of your mind that this approach may not be working “how” you think it’s working.

      Joseph Brence, DPT September 14, 2012 3:37 pm
  • There are more clients with motion dysfunction of the lumbopelvic-hip complex who are asymptomatic than those who are symptomatic. Because my work addresses the whole body and is prevention based I do treat these. however, I have a long-held mistrust of the traditional tests as mentioned above and presented a paper on this mistrust at the 1990 APTA national conference and at the World Congress on LBP & the Sacroiliac in 1992. A master’s thesis by Luanne Olson was presented at several World Congress’ following, presented on my system of palpation and spring testing of the pelvis which has a better reliability than the traditional tests. Much more important than being able to evaluate motion occurring “in the isolated SIJ” is the ability of motion to translate THROUGH the pelvic structures because extrinsic restrictors are just as relevant perhaps as intrinsic restrictors. The sprint tests are a modification of the tests used in manual therapy and are appropriately named “springing with awareness” described in a few book chapters an on my web site and in some you tube videos. A very expansive topic to cover so briefly here. I choose to evaluate the pelvic structure because it has significant reflexive effects on distal parts of the body, such as the upper cervical spine. At times a dramatic release of chronic cervicogenic headache can be accomplished by restoring normative anterior glide of the sacrum (takes me 15 minutes) and of the ilium (transverse plane Type I outflare). I will leave this as a brief post for now and invite you to become familiar with the work at my web site http://www.HeschInstitute.com
    We can do much better than the traditional model of so-called SIJ eval & treatment.
    Best Regards,
    Jerry hesch

    jerry hesch September 25, 2012 12:25 pm Reply
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  • From a chiropractic standpoint I agree with almost all of this. One thing to consider, however, although the provocation tests are reliable in determining if an SI joint is causing pain, it DOES NOT tell you an any way what to adjust/manipulate/mobilize. E.g., a hypermobile joint can be a source of pain, but the last thing you would want to do is increase motion. HIstory, mechanism of injury, and palpation is still necessary.

    Mark Jolley November 10, 2012 12:06 pm Reply
    • Unfortunately the pain provocation tests are problematic, and as you state, do not give an indication as to what is needed for treatment. Why else, are provocation tests problematic? For one thing they can and often do give a false negative. There are a large number of clients (I call them that-not “patients”) have subtle or overt biomechanical; dysfunction of the lumbo-pelvic-hip complex whether or not a true SIJD” I will defer for now. Best example are those with a reflex forward head because of a SYMMETRICAL NON-PAINFUL sacrum. Discerend with passive accessory spring testing and palpating ligamentous tone. When sacral mobility is restored the compensatory mid thoracic and upper cervical fixation restriction melts, spontaneous balance challenge much improved yadayaydaya. So I do not require that pain is provoked ion order to grant me permission to treat the SIJ. I would have missed the above in a person who sought care from all manner of clinicians and lots of manipulative specialists over 30 years. I treated her once. I follow up q 6 months and in 3 years have not had to retreat. The injections of which the pain provocation tests are based are weak at best.
      My son is visiting I am not able to do justice on this post but much of my efforts are directed at changing the SIJ pardigm and using research to assist. There are gaps in research, I get that. More later.
      Jerry Hesch
      Hesch Institute
      Murakami’s injection study is brilliant and ignored by too many. J Orthop Sci. 2007 May;12(3):274-80. Epub 2007 May 31.
      Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study.
      Murakami E, Tanaka Y, Aizawa T, Ishizuka M, Kokubun S.
      Department of Orthopaedic Surgery, Kamaishi Municipal Hospital, Kamaishi, Iwate, Japan.
      The sacroiliac joint (SIJ) can be a source of low back pain. Previous studies indicated that SIJ pain could originate from both the joint capsule and the posterior ligamentous tissues. It has not been clarified as to whether an intraarticular or periarticular injection procedure is more effective for this type of pain. The purpose of this study was to evaluate the effect of two injection procedures prospectively.
      After a pain provocation test, an intraarticular injection of local anesthetic (2% lidocaine) was performed on the first 25 consecutive patients with SIJ pain and a periarticular injection on another 25. The periarticular injections were given to one or more sections of the posterior periarticular area of the SIJ and to another section in the extracranial portion. The effect of these injections was assessed using the “restriction of activities of daily life” scoring system from the Japanese Orthopaedic Association.
      The periarticular injection was effective in all patients, but the intraarticular one was effective in only 9 of 25 patients. An additional periarticular injection was performed in 16 patients who experienced no effect from the initial intraarticular injection and was considered effective in all of them. The injection into the middle of the periarticular area was more effective for SIJ pain. The improvement rate after the periarticular injection was 96%, which was significantly higher than that after the intraarticular injection, which was 62%.
      For patients with SIJ pain, periarticular injection is more effective and easier to perform than the intraarticular injection and should be tried initially.

      jerry hesch November 10, 2012 1:42 pm
    • Thanks for the comment Mark. How do you detect a hypermobile joint and how do you know if that hypermobility is related to someone’s pain?

      josephbrence November 10, 2012 10:33 pm
    • Additionally, haven’t we seen suggestions in multiple studies that joint manipulation is not just for hypomobility, but also has pain modulating effects?

      Erik November 11, 2012 5:57 pm
    • In reply to Erik, As always, it depends on your goals of treatment. If your goal is simply pain control then I suppose manipulating a hypomobile joint might be suggested. My common sense tells me not to. Would you manipulate a shoulder separation? or an ACL sprain? Mechanoreceptive activation may block pain temporarily, but log term I think most people are better off focusing on fixing the root of the problem. Again, circumstances are always considered. And I don’t know of a reliable way to detect a hypomobile/fixated joint especially the SIJ. I use motion palpation technique (which focuses on end feel, not range of motion) and I’m very confident in most areas (personal INTRAreliablility, being able to palpate and find the same dysfunction repeatedly, is high with me). SI is tricky, though, because of the limited movement. Sometimes it is obvious, most times it is subtle or not detectable.

      mjolley November 12, 2012 9:53 am
    • Mark,
      I very much agree with your comments regarding the need for a thorough evaluation.
      An additional thought is that one actually can mobilize a hypermobile pelvic joint and gain stability. The SIJ is a unique joint that normally has a very small amount of available motion which is physiologically necessary, and the joint actually becomes more stable after moving, such as going recumbant to upright. It is typically very stable and very functional in extension, especially end-range extension. With respect to mobilize a hypermobile joint, the forces that I use and teach are very small aand are incapable of moving such a complex 3-D structure with a profound amount of connective tissue; except by the use of a fundamental property of connective tissue, viscoelastic creep. For the posterior glide sacral glide fixation, I use a minimum of 10 minutes. If I determine that a joint is hypermobile in one to 3 direction but find it to be hypomobile in the opposite directions, then by restoring motion in the direction in which it is lost, both sides very typically move towards the mean. The hypermobile become stable. This for several reasons, the form-closure is enhanced and the type II (and possibly the IV) are facilitated and of course the others as well and the end-result being that muscle function is enhanced, ligament tone is enhanced because muscle has a profound amount of ultimate (dense fascial expansions) origin and insertion on ligament, especially in the pelvis. So the correct mobilization of a “hypermobile joint” can be a stabilizing procedure. True global Sj instability with true hypermobility in all directions unamenable to our ministrations is very rare and when it is present is typically a surgical condition. I do have a fascinating case study on a woman in the 9th month of pregnancy who felt very unstable, antalgic gait, poor bladdr control, moved in a very protective manner keeping knees together felt like she was splitting apart. She was not. She was hypomobile, suck, stuck stuck SIJ & symphysis pubis. This case is posted on my web site and presented at World congress on LBP & Pelvic Pain 2010. I look forward to hearing how you and Joseph determine if hypermobility is or is not a part of a persons experience of pain.

      jerry hesch November 11, 2012 7:06 am
    • In reply to Jerry. Make sense. When I find a hypermobile SI I first focus on the nearby fixated joints and global regional stabilization using rehab. If that fails I generally try (with little success I might add) an SI locking belt. Lastly I send my patients for prolotherapy and give up.

      mjolley November 12, 2012 9:59 am
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  • This is an interesting study on a medial to lateral PSIS stress test for pain provocation. I have critiqued the article, of course “further research needed” but of preliminary interest.” http://www.biomedcentral.com/content/pdf/1471-2482-13-52.pdf With respect to true pubic joint dysfunction and rupture (symphyseal diastasis) the use of objective imaging such as AP pelvic and MRI is helpful, but must acknowledge that recoil can give a false negative, and only one author has specifically addressed this in the real world, demonstrating that a pelvis stress test with x-ray can show much greater instability at pubic joint joint, in fact upped the dx in one to surgical instability. I abandoned the gross movement SIJ (so-called) tests somewhere ion the early 80’s presented a paper on that at APTA national and World Congress on LBP and the Sacroiliac 1990, 1992. The so-called SIJ pain provacation tests have significant inherent challenges per good injection research. In spite of objective imaging, this is a very underserved population. They deserve our engagement lest we be accused of being male chauvanists medical patriarchs. I have seen that movie. Embracing the known with cautious externalization of research findings with the balancing of acknowledging the unknown within a contextual framework of EBP (ALL FACETS), may save the day until additional research shall guide us and prevent us from ignoring a relevant issue that affects child-bearing population. Some are still damaged from intentional cutting of symphysis to facilitate early birth… Jerry Hesch

    JERRY HESCH, MHS, PT, DPT(s) September 27, 2014 11:55 am Reply
  • It remains an important conversation, especially as we have some trends but there remains a need for additional research and effort to optimize patients all the while acknowledging the recent imposition of greater complexity with the medical equipment manufacturers advertising their sacroiliac fusion hardware best described as juggernaut advertising, and patients coming for services with a strong belief that the diagnosis “SIJD or sacroiliac joint dysfunction” accurately describes what they experience. The call for the rehab community to optimize care is ever present, and clinicians who advertise themselves as experts who participate in the fusion market seem unbridled. Try these key word searches: “sacroiliac fusion physical therapy” “Gainsville Georgia Vicki Sims sacroiliac fusion, etc”. I invite your participation as if one is not part of the solution, then one becomes part of the problem. I have acted. Please help.

    jerry hesch, mhs, pt, dpt(s) October 13, 2014 3:08 pm Reply
  • Informative piece , For my two cents , people are searching for a a form , my secretary used a fillable version here https://goo.gl/nbil3P.

    marielsimones July 14, 2016 3:34 am Reply
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