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

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Evidence-Based Evaluation & Treatment of the Sacroiliac JointJames R. Scifers, DScPT, LAT, ATC

Moravian CollegeAthletic Training Program

Pelvic Anatomy

n Innominatesn ischiumn iliumn pubis

n Sacrum

Articulations

n Sacroiliac Jointsn Pubic Symphysisn Lumbo-Sacral Joint

Biomechanics of the Pelvis

n Function of the SI Jointn transmit vertical forcesn transmit ground reaction forces

Sacral Motions

n During trunk flexion…n Initially, sacral flexion occurs (base of sacrum moves anterior)

n Later, sacral extension occurs with continued trunk flexion (base of sacrum moves posterior)

Arthrokinematics of the SI Joint

n Sacral Base (S1)n Sacral Apex (S5)n Flexion (nutation)

n occurs during exhalation

n Extension (counternutation)n occurs during inhalation

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Dysfunction Classification

n Sacroiliac Joint (SIJ)n Any injury to SIJ

n Ilio-Sacral (IS)n ilium (innominate) moving on sacrum

n Sacro-Iliac (SI)n sacrum moving on ilium

n Pubic Shearn Pubic symphysis / Pubic shear lesion

Ilio-Sacral (IS) Dysfunctions

n Named for motion at PSISn anterior rotationn posterior rotationn up-slipn down-slip (rare)n in-flaren out-flare

Sacro-Iliac (SI) Dysfunctions

n Sacral Rotationsn Named for “direction facing on axis”

n Forward Rotationsn right on rightn left on left

n Backward Rotationsn right on leftn left on right

Pubic Shear Lesions

n Named for any movement at pubic symphysis

n Indicates injury to pubic symphysis

SI Evaluation

n History*n Observation**n Palpation**n AROM / PROMn MMTn Special Tests*n Neurologic Exam

Evidence-Based Practice (EBP)

n Reliability (k) is reproducibility of test results, can be intra-tester (within one clinician) or inter-tester (between multiple clinicians)

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

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

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Evidence-Based Practice (EBP)

n Positive Likelihood Ratio (+LR) indicates the likelihood that a POSITIVE test means the condition is present

n 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

n SI pain typically unilateral, may refern Pain typically localized to involved SI joint

n Sens = .76, Spec = .47, +LR = 1.4, -LR = 0.511

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

n MOI may include falling or twistingn MOI more often insidious (48 hour rule to assess for cause)n Aggravating Activities usually includes sitting

n 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

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

n Observe for spasmn erector spinae

n Observe muscle tonen gluteals

n Observe symmetry:n PSISn Iliac Crestsn ASISn Greater Trochantern Pubic Tubercle

Palpation4-6

n Standing:n ASISn PSIS (k = .13 - .37)n Iliac Crests (k = .23 - .41)n Greater Trochanters

n Prone:n Sacrumn Inf Lat Angle of Sacrum (k = .69)n Sacral Sulcus (k = .24)n Sacrotuberous Ligamentn Piriformis (or s idely ing)

n Supine:n Pubic Tubercle

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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 ASIS Palpation

PSIS Palpation Iliac Crest Palpation

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Alignment & Symmetry

n Iliac Crest Heightsn higher or lower

n PSIS Relationshipsn superior-inferiorn medial-lateral

n ASIS Relationshipsn superior-inferiorn medial-lateral

n Greater Trochanter Levelsn higher or lower

n Sacral Sulcus Depthsn deeper or shallowern superior& inferior

n Inferior Lateral Angle of Sacrumn 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

n AROM tested in standing or sitting

n PROM tested in supine or prone

n Stress at SI Joint:n Spine flexion 40-60°n Spine extension 20-35°n Spine rotation 3-18°n Spine side glide 15-20°n Hip flexion 100-120°n Hip extension 0-15°

SORT

CClinical Application: Pain increased with AROM or PROM Hip Extension to end-range can help differentiate SIJ pathology from Lumbar Spine pathology

Manual Muscle Testing

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

n Abdominals

n Hip flexionn Hip abduction

n Gluteus Mediusn Gluteus Minimus

n Hip adductionn Hip extensionn Knee flexionn Trunk extension

n Bridging

SORT

CClinical Application: Pain increased with bridging is often indicative of SIJ pathology

Neurologic Assessment

n Should be normal in presence of SI dysfunctionn Dermatomes (L1-S2)n Myotomes (L1-S2)n Reflexes

n Patellar Tendon (L3-L4)n Achilles Tendon (S1-S2)

Special Tests

Pain Provocation Testsn Straight Leg Raise Testn Gaenslen Testn Thigh Thrust Testn FABER / Patrick’s Testn Gapping Testn Compression Testn Sacral Spring Testn SI Rock Testn Flamingo Test

Positional Testsn Trunk Flexion Testn March Testn Supine to Sit Testn True LLD Testn Apparent LLD Testn Trendelenburg’s Signn Thomas Test

Special Test Literature

n Provocation Tests have little predictive value in isolation or combination1

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

n Positional Special Tests performed in combination greatly increase value of findings 7-10, 22-23

SORT

AClinical Application: SIJ special tests should always be used diagnostically in combination & not in isolation

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n Laslett, et al (2005)23

n 2 of 4 Positive Special Testsn Thigh Thrust, Distraction, Compression & Sacral Spring

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

Sens. Spec. + LR - LR.88 .78 4.00 0.16


n Van der Wuff, et al (2006)22

n 3 of 5 Positive Special Testsn Thigh Thrust, Distraction, Compression, Patrick’s & Gaenslen’s

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

Sens. Spec. + LR - LR.85 .79 4.02 0.19


n Laslett, et al (2003)7

n 3 of 5 Positive Special Testsn Thigh Thrust, Distraction, Compression, Gaenslen’s & Sacral Spring

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

Sens. Spec. + LR - LR.91 .87 4.16 0.11


n Cibulka & Koldehoff (1999)9

n 4 of 4 Positive Special Tests, 219 subjectsn Standing Flexion, Sitting PSIS Palpation, Supine to Sit & Prone Knee Flexion Test

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

Sens. Spec. + LR - LR.82 .88 6.83 0.20

Straight Leg Raise Test

n Clinician passively flexes hip with knee extended

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

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

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

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

All data for detecting lumbar disc herniation, not SIJ pathology11

Sensitivity Specificity + LR - LR0.78-0.97 0.10-0.57 1.00-1.98 0.05-0.35

Gaenslen Test

n Patient is supine with both legs extended

n Uninvolved knee is brought to chest while involved hip remains in extension

n Overpressure is applied to involved side

n Positive test is pain indicating SIJ involvement

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


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Thigh Thrust Test

n Patient is supinen Involved hip is flexion and adducted

n Posterior shearing force is applied through femur in varying degrees of hip adduction / abduction

n Positive test is buttock pain indicating SIJ involvement

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


FABER or Patrick Test

n Patient supine with hip positioned in flexion, abduction and external rotation

n Clinician applies over-pressure at knee toward table while stabilizing opposite ASIS

n Positive test is pain indicating SIJ pathology

n If patient exhibits a decrease in pain, an out-flare should be suspected

K = .60 - .621, 6 , 21


Gapping or Distraction Test

n Patient supine n Clinician applies crossed-arm outward pressure on the ASIS

n Positive test is pain, indicating SIJ pathology

n If patient reports relief of pain, an out-flare should be considered

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

Sensitivity Specificity + LR - LR0.55-0.60 0.81-1.00 3.20 0.49

Compression Test

n Patient is positioned in supine or sidelying

n Clinician applies medial pressure at iliac crests to compress ASIS

n Positive test is pain indicating out-flare

n Relief of pain indicates SIJ pathology

K = .26 - .736, 17-20


Trunk Flexion Test

n Palpate PSIS bilaterally in sitting or standing

n Painful PSIS is lowern Painful PSIS rises higher during flexion

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

n Positive test indicates posterior rotation

K = .08 - .68 4-6, 12-14Sensitivity Specificity + LR - LR

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

Gillet or March Test

n Patient brings knee to chest in either standing or sitting

n Clinician looks for downward motion of PSIS

n Uninvolved side will move inferiorly, involved side will move less or not at all

n Positive test indicates posterior rotation

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

Sensitivity Specificity + LR - LR0.43 0.68 1.3 0.84

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Supine to Sitn Patient is supinen Patient performs a bridgen 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 lengthn posterior rotation: short to longn anterior rotation: long to shortn LLD: long to long or short to short

Sensitivity Specificity + LR - LR0.44 0.64 1.37 0.88 K = .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

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

Sensitivity Specificity + LR - LRN/A N/A N/A N/A

Thomas Testn Patient is supine at edge of table

n Uninvolved knee is passively brought to chest

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

n Associated finding with anterior rotation

n Knee extension (tight RF)n Associated finding with anterior rotation

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


Sacral Thrust or Sacral Springing

n Patient is pronen Clinician applies downward pressure to sacrum

n Positive test is pain, indicating sacral rotation

n Test can be repeated on four corners of sacrum

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


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SI Rock Test

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

n Positive test is buttock painn Indicating involvement of sacrotuberous ligamentn left on right rotation n right on left rotation


Flamingo Test

n SLS causes or increases pain on involved side---may also include buttock pain

n Patient may be asked to hop on one leg to increase or cause pain

n Positive test is indicative of SIJ pathology OR pubic shear lesion


Special Test Take-Home Points

n Perform special tests in combination to improve diagnostic accuracy

n Best tests for ruling-in SIJ pathology are FABER, Thigh Thrust, Gaenslen & Gapping Tests

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

n Best tests for ruling-in posterior rotation are March & Supine to Sit Tests

SORT

A

SORT

B

SORT

C

SORT

B

Special Test Take-Home Points

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

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

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

SORT

B

SORT

C

SORT

B

Treatment Strategies

n Muscle Energy Techniques

n Joint Mobilization Techniques

n Stretching Techniquesn Strengthening Techniques

n Dynamic Lumbar Stabilization

Movement / Resistance Key

n Isometric Patient Generated Force n Clinician Generated Force

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Anterior Rotation

n Problem List?n MET

n Hamstringsn Joint Mobilizations

n Posterior Mobilization

n Stretchingn Rectus Femoris & Hip Flexors

n Strengtheningn Hamstrings & Core

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

SORT

C Posterior Rotation


n Quadricepsn Joint Mobilizations

n Anterior Mobilization

n Stretchingn Hamstrings

n Strengtheningn Quadriceps & Core

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

SORT

C

Upslip

n Typically secondary to trauma


n Nonen Joint Mobilizations

n Inferior Glide / Long Axis Distraction

n Stretchingn None

n Strengtheningn None 5 degrees hip flexion, 30 degrees hip

abduction with hip ER or hip IR

SORT

C In-flare


n Adductorsn Joint Mobilizations

n Out-flare Mobilization (forced hip adduction with flexion…SI Rock Test)

n Stretchingn ITB & TFL

n Strengtheningn Adductors & Core

SORT

C

Alternate In-flare MET Out-flare


n Abductorsn Joint Mobilizations

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

n Stretchingn Adductors

n Strengtheningn Gluteus Medius / Minimus & Core

SORT

C

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Out-flare Mobilization Right on Right Sacrum


n None n Joint Mobilizations

n Sacral Springing on inferior right angle of sacrum

n Othern Stretch / Treat Right Piriformis & Strengthen Core

SORT

C

Left on Left Sacrum



n Sacral Springing on inferior left angle of sacrum

n Othern Stretch / Treat Left Piriformis & Strengthen Core

SORT

C Right on Left Sacrum



n Sacral Springing on superior right angle of sacrum

n Othern Address left STL pain & Strengthen Core

SORT

C

Left on Right Sacrum



n Sacral Springing on superior left angle of sacrum

n Othern Address right STL pain & Strengthen Core

SORT

C Sacral Mobilizations

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Order of Treatment Procedures

n Pubic Lesionsn Sacral Lesions (SI)n Innominate Lesions (IS)n Dynamic Lumbar Stabilizationn Function Strengthening / Progression

SORT

C

Referencesn 1 Dreyfuss, et al (1996). The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine, 21: 2594-2602.

n 2 Slipman, et al (2000). Sacroiliac joint pain referral zones. Archives of Physical Medicine & Rehabilitation, 81: 334-338.

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: 1889-1892.

n 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.

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.

Referencesn 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.

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

n 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.

n 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.

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

n 12 Vincent-Smith & Gibbons (1999). Inter-examiner and intra-examiner 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.

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

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

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

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

n 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.

Referencesn 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.

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

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