Sacroiliac Joint Tests – Uses, Indications, Types, Procedure

It’s often difficult to diagnose sacroiliac (SI) joint dysfunction, especially since the main symptom is low pain?: Back pain means pain in the spine, muscles, discs, joints, or nerves of the back. সহজ বাংলা: পিঠ/কোমরের ব্যথা।" data-rx-term="back pain" data-rx-definition="Back pain means pain in the spine, muscles, discs, joints, or nerves of the back. সহজ বাংলা: পিঠ/কোমরের ব্যথা।">back pain?, which is common to many different painful spinal disorders. In fact, SI joint dysfunction occurs more frequently than many doctors realize. And sometimes it is difficult to differentiate between low back pain and hip pain. There are various exams and tests that can help determine whether you have SI joint dysfunction.

Anatomy

It is the largest axial joint in the body. The size, shape, and surface contour shows wide individual variation. SIJ is an auricular or C- shaped joint. It lies between the first to the third sacral vertebrae. Only the anterior portion is a synovial joint and the posterior portion contains the strongest ligament? in the body, the interosseous sacroiliac ligament. The innominate side is covered by fibrocartilage and the sacral side is covered by articular cartilage?. The cartilage of the sacral side is thicker than the iliac side. The sacral side has a central depression and the innominate side has a central ridge.

The stability of the sacroiliac joint is provided by the sacroiliac ligaments and accessory ligaments. The sacroiliac ligaments are the anterior and posterior sacroiliac ligaments and the interosseous ligaments. The ligaments are thicker posteriorly than anteriorly. Anterior sacroiliac ligaments are thickenings in the joint capsule. Interosseous ligaments are the most important and have superficial and deep portions which in turn are divided into superior and inferior bands. Posterior ligaments connect the lateral sacral ridge and the posterior iliac spine and iliac crest. The Accessory ligaments include the iliolumbar, sacrotuberous, and sacrospinal ligaments.

The structure of the sacroiliac joint evolves with the age of the person. These changes begin after puberty and continue through one’s lifetime. During adolescence, the iliac side becomes rougher and develops areas of fibrous plaques. The changes accelerate after the third and fourth decade with surface irregularities, fibrillation, and crevice formation. Sacral side changes begin 10-20 years after the iliac side changes. The joint develops fibrous ankylosis by the sixth decade. Erosions and plaque? formation become widespread by the eighth decade.

The innervation of the sacroiliac joint is not yet clearly established. As per various reports, the posterior part of the joint is innervated by branches from the dorsal rami of L3- S3, and the anterior third is innervated by branches from the ventral rami of L2-S2. Innervation from multiple segments leads to referral of pain? from sacroiliac joint to different anatomical regions and diverse pain patterns can be observed. But the pain from SIJ does not refer to areas above L5.

Biomechanics

The primary function of the sacroiliac joint is to provide stability. It transmits the weight of the trunk to the lower limbs. It is weak in torsion and axial compression. The sacroiliac joint provides only small degrees of movement in all 3 axes. In males, the movement is predominantly translational and in females it is rotational. Movements are more in females.

Forward rotation of the sacrum at the SIJ is called nutation. During nutation, the sacral promontory moves anteriorly and inferiorly and the coccyx moves posteriorly and superiorly. This leads to a decrease in the anteroposterior width of the pelvic brim and an increase in the anteroposterior width of the pelvic outlet. The backward rotation of the sacrum with opposite effects is called counter-nutation. These movements are probably important during childbirth.

History

Pain? in the sacroiliac region may be either due to localized? causes or referred causes. Pain over the SIJ may be referred from an intervertebral disc or facet joint lesions. In addition, the pain of sacroiliac joint lesions may radiate to the buttock, lower lumbar? region, or buttock. Hence it is often difficult in many patients to identify the exact source of pain.

The cause of the pain? may be intra-articular or extra-articular. Intra-articular causes may be swelling?, stiffness?, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।" data-rx-term="arthritis" data-rx-definition="Arthritis means joint inflammation causing pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।">arthritis?, infection?, or trauma. Extra-articular causes may be enthesopathy, fractures, ligamentous injury, or lesions of adjacent ilium, sacrum, or soft tissue structures. Causes may be classified as an inflammatory disease, infection, tumor, metabolic disorders, degenerative disease, iatrogenic conditions, referred pain, and trauma.

Limb length discrepancy, abnormal gait, prolonged exercise, or scoliosis may lead to mechanical derangement of the sacroiliac joint leading to pain?. Pregnancy is a well-known risk factor for sacroiliac pain due to weight gain, excessive lumbar? lordosis, injury during delivery, and hormone-induced ligamentous laxity.

Symmetrical or asymmetrical sacroiliitis is a common finding in spondyloarthropathies.   Ankylosing spondylitis commonly causes symmetrical involvement and other spondyloarthropathies lead to asymmetrical involvement.

Examination and Manual Test of Sacroiliac joint tests

Many of the problems of the sacroiliac joint are missed and often attributed to hip or spine disease as the history and clinical tests are often nonspecific. Careful physical examination is needed for proper diagnosis?.  Point-specific pain? when an area is touched or pressed. সহজ বাংলা: চাপ দিলে ব্যথা।" data-rx-term="tenderness" data-rx-definition="Tenderness means pain when an area is touched or pressed. সহজ বাংলা: চাপ দিলে ব্যথা।">tenderness? at the sacral sulcus or posterior superior iliac spine is a consistent finding in sacroiliac joint lesions. Tests for sacroiliac joint can be divided into motion palpation tests and pain provocation tests. Gillet test is the most commonly done motion palpation test.

The

Gillet test

Patient position- Standing.

Examiner position- Standing behind the patient, with one thumb over the S2 spinous process and the other thumb over the posterior superior iliac spine (PSIS) of the tested side.

Procedure- Ask the patient to maximally flex the hip on the tested side.

Interpretation- Normally PSIS moves inferiorly in relation to the S2 spinous process. If it remains at the same level then there is SIJ dysfunction.

The provocative tests done for the sacroiliac joint do not test the sacroiliac joint alone; hence lesions in the adjacent structures also will elicit a positive test. This is the main reason for lack of specificity for these tests.

Sacroiliac distraction test

Patient position- supine on a couch.

Examiner position- Standing with each hand placed over the anterior superior iliac spine on either side.

Procedure- Apply posterior directed force to distract the sacroiliac joint.

Interpretation- Pain? at the sacroiliac region is suggestive of sacroiliac pathology.

Thigh thrust test

Patient position- supine on a couch with the hip and the knee flexed to 90⁰ and the hip slightly adducted.

Examiner position- Standing with one hand placed over the sacrum and the other upper limb wrapped around the knee.

Procedure- Apply posterior directed force to the vertically oriented femur to apply a shearing force on the sacroiliac joint.

Interpretation- Pain? at the sacroiliac region is suggestive of sacroiliac pathology.

Gaenslen’s test

Patient position- Supine with one limb hanging over the edge of the couch.

Examiner position- Standing.

Procedure- Maximally flex one lower limb onto the abdomen and maximally extend the other hip hanging beyond the edge of the couch.

Interpretation- Pain? at the sacroiliac region is suggestive of sacroiliac pathology.

Sacroiliac compression test

Patient position- Lateral position with hip and the knee bend to 90⁰.

Examiner position- Standing with both hands placed on the iliac crest.

Procedure- Apply firm pressure on the iliac crest.

Interpretation- Pain? at the sacroiliac region is suggestive of sacroiliac pathology.

Patrick test or FABER (Flexion-Abduction-External rotation- Extension) test or Figure 4 test

Patient position- Supine

Examiner position- Standing.

Procedure- Ask the patient to keep the hip in flexion-abduction-external rotation position, knee in 90⁰ flexions with the foot resting on the opposite limb. Apply pressure on the knee to force the hip into extension.

Interpretation- Pain? felt in the region of SIJ is suggestive of SIJ lesions.

RAB (Resisted abduction) test

Patient position- Supine.

Examiner position- Standing holding the patient’s leg at the ankle.

Procedure- Ask the patient to abduct against resistance.

Interpretation- Pain? felt in the region of SIJ is suggestive.

Sacral thrust test

Patient position- Prone position.

Examiner position- Standing with both hands placed on the sacrum.

Procedure- Apply firm pressure on the sacrum.

Interpretation- Pain? at the sacroiliac region is suggestive of sacroiliac pathology.

Yeoman test

Patient position- Prone position.

Examiner position- Standing and holding the patient’s tested lower limb at the knee.

Procedure- Hyperextend the hip.

Interpretation- Pain? at the sacroiliac region is suggestive of sacroiliac pathology.

The thigh thrust test is most sensitive and the distraction test is the most specific. Only the thigh thrust test reaches more than 80% sensitivity and specificity. In the absence of centralization, if three provocative tests are positive then the sensitivity, specificity, and positive likelihood ratio are 93%, 89%, and 6.97%, respectively. Hence practically it is sufficient to do the thigh thrust test, sacroiliac distraction test, and the FABER test to arrive at a diagnosis?.

References