sacroiliac joint dysfunction

[arifa]

Hello

need some help with SIJ assessment. How does an upslip present in terms of levels of ilac crests, stork test, level of PSIS during lumbar flexion?
There are lots of tests out there for SIJ, which ones are the most accurate?

Thank you
Arifa

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[linbin]

hi friend
please refer books of
greenman
diane lee

[CenteredHealth]

Hi Arifa,

Both authors which Linbin has suggested will be very helpful in assessment and treatment of pelvic girdle and sacroiliac dysfunctions.

Until you get those books... An upslip presents itself just as it sounds, the entire pelvis (right or left) is sheared up on one side. Therefore on palpation every bony landmark will be superior on one side, i.e. ASIS, iliac crests, PSIS, ITs, and pubis. As far as tests go, there are lots of them and depending on who you read the reliability will vary. Both the stork test and PSIS levels on lumbar flexion are pretty common ones and generally relied upon, however a positive test alone does not indicate an upslip, which is why palpation is so important. A positive test will only indicate the side of dysfunction, correct assessment then needs to be made by palpation in order to find the type of dysfunction, i.e. upslip, anterior rotated pelvis, inflare, outflare etc. I would also recommend the squish test, which is as simple as compressing the SIJs anteriorly through the ASISs on a supine patient. Here, hypomobility indicates the side of dysfunction.

Good luck and again, I would suggest picking up the above books.

[jesspt]

There are lots of tests out there for SIJ, which ones are the most accurate?

A very interesting question, especially in the area of the sacroiliac joint. I've attached a few articles which essentially look at how accurate a physical exam is compared to SIJ injections. They may stimulate some discussion.

[CenteredHealth]

Having yet to read the articles that JessPT has kindly posted, I will go out on a limb and ask... Does the absence of SIJ symptoms equate absence of SIJ dysfunction?

[sharileedahl]

Will jump back in on this discussion after reading the articles provided by jesspt (Thanks).

But first a few thoughts...

Regarding the initial post:
There are a lot of tests for the SIJ in terms of position, mobility... My understanding is that any of the tests on their own are iffy. However when multiple tests are used, the validity/reliability of your findings improve greatly. So best to know lots of tests....do lots of tests...understand what they (the tests) are telling you....then critically think your way through all your findings to solve the puzzle. I had once heard that Diane Lee said she felt she could get most of her findings from observing the client do a single leg stand test. As I practice longer, I can see what she is saying (although I'm not quite there yet!!) however when I was a new grad there is no way I would have been able to see everything I needed to see from that one test.

Regarding upslips, anteriorly rotated pelvis etc.....
Do you guys feel that you see true upslips very often ...
I ask this because when I compare my position testing to mobility testing etc I often find that the issue is somewhere else and not specifically at the SIJ. i.e. myofascial tightess (QL / psoas / gluts / / / ) or lower Lsp (L4/5, L5/S1...perhaps some segmental facilitation creating increased muscle tone???)
The handful of times that I have felt hypomobility at the SIJ along with either an upslip or fixation in rotation, manually treating the SIJ (mobilization - Grade 4 or 5) has worked great....great outcomes....lasting benefits....blah,blah,blah! HOWEVER, the majority of the time, I feel like I'm wasting my time even fiddling around with manual therapy in the area because the improvements may only last minutes. And yes, we spend alot of time trying to retrain muscle balance in the area too but I'm not convinced adding the SIJ manual therapy improves on outcomes more than just doing the exercise alone. What do you think????
(This is an area that I've put on my list of things to learn more about....course coming up this fall!)

[CenteredHealth]

Seeing true upslips...

They are not too common, the reason being is that they are not physiologically movements of the body and typically only occur as a result of a trauma. The physiologically motions of the pelvis include the anterior/posterior rotations and the in/outflares. These are classified as physiological because they occur naturally, i.e. during the gait cycle. The non-physiological movements (the upslips and downslips) occur secondary to a trauma, i.e. a fall down the stairs, on ice, etc. The shearing of the pelvis on the sacrum would occur because of the force from the fall. Think about it; it's going to take a lot of force to shear the SIJ.

As sharileedahl has so aptly put it; there are other factors that can 'fake' an upslip. The most common being myofascial tension through the QL, psoas, or lumbar spine unilaterally. Of course a proper assessment needs to be made in order to properly diagnosis and treat the lumbopelvic complex. Chances are that if there has never been a significant trauma to the pelvis (i.e. a fall) then it would be safe to say that there is no upslip.

As far as treating the SIJs manually, I have seen miracles happen. I will tell you a quick story regarding a neurosurgeon who came to us for treatment. He had a significant disc protrusion verified via MRI, had gone to many of his colleagues for opinions, all of whom had told him he needed surgery. Being fully aware of the implications of the proposed surgery he wanted to exhaust all other options before going under the knife. Fortunately for us, we got to work together. We began by manually correcting his pelvic, sacral, and lumbar spine mechanics. Things began to turn around immediately. We would integrate this with minimal and basic exercises, more along the lines of re-education, i.e. pelvic tilts. It took some time but now he is pain free and has better motion than before.

In short, there is a lot to be said of correcting a persons structure in order to positively influence their function.

[linbin]

hi
the reliability and validity of the tests used to assess SIJ dysfunction is not good enough ,to confirm the dysfunctions
there are master class articles of peter o' Sullivan in manual therapy 12 ,2007.i feel it will help to look at these dysfunctions from a different perspective
eager to hear the views
cheers

[sharileedahl]

OK...I read the two articles provided by "jesspt"....
Both referred to pain provocation tests. I think everything I have read and learned from courses has reiterated the same.....provocation tests for the SIJ are reliable if two or more are done. Although I did learn that if there are discy signs / symptoms, SIJ tests are not reliable....hadn't heard that before (or maybe I wasn't paying attention!!!).

The tests that cause more disagreement / contraversy are those related to function / mobility. It is these tests that I believe are more reliable if a number of tests are done (as I stated in my last reply). I have looked through the journals that I have handy (that I have recently read)...of course I can't find the one I was thinking of so I'll keep looking around as it will be useful for me to review.

I did however find a review that Diane Lee did of another article (Robinson HS et al. "The reliability of selected motion and pain provocation tests for the sacroiliac joint." Manual Therapy, 12(1), 2007). Related to pain provocation tests, she agrees with the authors that there is sufficient evidence re. the reliability of pain provocation tests. She was somewhat critical of their negative results of motion tests. One reason for her criticism of the conclusions drawn by the authors was that they were comparing their results to other studies done with other tests rather than comparing the same test....."This is a significant problem since it appears that the authors believe that all joint play tests are the same." One of the tests that the authors reviewed were mobility tests done in prone where the SIJ is already near its close-packed position. The second criticism she reported was the lack of standardization of testing to minimize the impact of the myofascial system which has been shown to increase stiffness at the SIJ (i.e. TrA, multifidus, pelvic floor). Ultimately her feeling is, "In the clinic, the findings from any joint play test (passive accessory mobity test) is correlated with the findings of several other tests (passive physiological mobility test, active physiological mobility tests, stability tests) before a motion diagnosis is made."

Diane Lee's final conclusion in this review was this:
"In conclusion, I think we can safely say that pain provocation tests for the SIJ are reliable when two or more tests which stress the joint are positive. The validity of these tests to truly incriminate the sacroiliac joint as opposed to the extra-articular tissues has yet to be determined. With respect to motion analysis, this study has shown that evaluating motion of the SIJ in the prone position without consideration of any neuromyofascial resting tone or contraction is not reliable. They have not shown that all joint play tests are unreliable, that remains to be tested and discussions are underway to design a study which evaluates motion at the SIJ and takes in to consideration the multiple variables that can influence the outcome of the test and thus its reliablility."

Lee, Diane. "Article Review: "The reliability of selected motion motion and pain provocation tests for the sacroiliac joint."" Orthopaedic Division Review, Nov/Dec 2007.

[jesspt]

Centered -

Having yet to read the articles that JessPT has kindly posted, I will go out on a limb and ask... Does the absence of SIJ symptoms equate absence of SIJ dysfunction?
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I suppose that this is where the conversation can get a bit tricky....it depends on how one defines dysfunction.

For my part, if I stress the joint and no symptoms are reproduced with any provocation testing, I move on to another hypothesis for the patient's problem.

[sharileedahl]

Centered -

I suppose that this is where the conversation can get a bit tricky....it depends on how one defines dysfunction.

For my part, if I stress the joint and no symptoms are reproduced with any provocation testing, I move on to another hypothesis for the patient's problem.

I'm with "jesspt" on this one. The majority of our tests are done in a stationary position therefore even without positive testing, arguably there could be some "SIJ dysfunction" with functional movements (i.e. during the gait cycle).
However, without positive signs and symptoms at the SIJ, I would not likely specifically treat the SIJ (i.e. if we are talking specific manual therapy techniques) believing the true issue is elsewhere. I would treat other areas (where ever positive findings are found) that could of course affect SIJ function via direct mechanical attachments (lower Lsp) or direct / indirect myofascial connections (basically any musculature (tightness, weakness, imbalance....whatever) throughout the Tsp, Lsp, pelvic girdle, L/E etc....
Rereading this, it sounds like I've flip-flopped a little BUT .... based on what I have seen, I don't always think that what appears as SIJ dysfunction with kinetic testing can actually be treated effectively by just addressing the SIJ. All the other "stuff" around the joint seems to be the real issue. (I guess that is what I was getting at with my question on 02-07-2008).

[linbin]

hi
if the tests for SIJ dysfunction comes as positive on one side and on further evaluation you discovers that certain muscles of the lumbopelvifumeral complex is showing unilateral tightness.then i think we should address the tightened tissues first and reevaluate the patient.since it has been mentioned that myofascial structure misbalances will lead to SIJ dysfunction .for long term results it seems to be the ideal approach along with strengthening of weak muscles and ergonomic care

[neuromuscular]

A very interesting question, especially in the area of the sacroiliac joint. I've attached a few articles which essentially look at how accurate a physical exam is compared to SIJ injections. They may stimulate some discussion.

I do not find any test of the SIJ as valid.

I have suggested that the bigger picture is APAS, asymmetric pelvic angle syndrome. My article was published in the Alberta Pysiotherapy News of August 2002.

The test is to landmark the ASIS to ASIS, PSIS to PSIS, ASIS to PSIS(R&L) and then do hip abdcution directly lateral in the coronal plane. You will not see much if you do not do hip abduction. The suggested foot stances are 15 cm, 30 cm, 45 cm, 60 cm, 75 cm, 90 cm, etc. to the extent that the patient can perform.

If you want to do a simple check if the SIJ test that you are using is accurate and truly showing a "fixation" of the SIJ, simply landmark the PSIS to sacrum and have the patient do hip abduction directly lateral in the coronal plane. For every supposed "stuck" or "fixation of" the SIJ, the PSIS will move superior and lateral to the sacrum.

Hope this is helpful.

Neuromuscular

[neuromuscular]

Having yet to read the articles that JessPT has kindly posted, I will go out on a limb and ask... Does the absence of SIJ symptoms equate absence of SIJ dysfunction?

Try the test for APAS. It will give you more insight.

Or try a simple test of PSIS to sacrum with hip abduction. The positive of other tests will be a negative with this test. The PSIS will move superior and lateral to the sacrum.

The true picture is APAS.


Hope you find this helpful.

Best regards,

Neuromuscular

A research papoer is being prepared on APAS by the OGI.

[neuromuscular]

Hello

need some help with SIJ assessment. How does an upslip present in terms of levels of ilac crests, stork test, level of PSIS during lumbar flexion?
There are lots of tests out there for SIJ, which ones are the most accurate?

Thank you
Arifa

If you have a positive for the "supposed stuck SIJ" . Try this

Landmark PSIS to sacrum. Have the patient do hip abduction directly lateral in the coronal plane. For every positive "fixation" of the SIJ, this test will show a superior and lateral movement of the PSIS to the sacrum with little variance.

My reseach was published as an article in a Canadian journal and is being pursued in the USA by a Lincoln Nebraska Clinic. The paper should be published in 2008 or early 2009.

APAS, asymmetric pelvic angle syndrome is the true cause of most of the supposed SIJ problems - form closure, force closure et al included.

Hope you find this helpful.

Best regards,

Neuromuscular.