Challenges of SI Testing: Part 1

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Challenges of SI Testing: Part 1

Does the sacroiliac joint move?  This have been one of the most contentious issues in sacroiliac joint (SIJ) research (Vleeming, 2012).  Studies up until 1634 suggested the SIJ only moved during pregnancy.  In the 17th century, the SIJ was reported to have a synovial membrane, confirming its mobility.  By the mid-19th century, researchers demonstrated that most of the sacral movement occurred around a transverse axis and was named ‘nutation’ (forward nodding) and ‘counternutation’ (backward nodding).  In 1864, Von Luschka described the joint as a real diarthrosis, i.e. a mobile joint with a joint cavity between two bony surfaces.  In 1909, Albee used a specific staining technique to validate the synovial nature of the SIJ and confirm joint mobility.

The SI joint is stabilized by a network of ligaments and muscles. The normal sacroiliac joint has been shown to have approximately 2-4 mm of movement.  So yes, the SIJ does move!

The next step is attempting to assess such a small quantity of movement.  There are at least 15 tests in the literature to incriminate the SIJ.  We will explore 8 in The Challenge of SI Testing – Part 1 and 6 in The Challenge of SI Testing – Part 2 (next week).

In addition to the test descriptions, the metrics, and the clustering of test results will be discussed.  The 8 tests included in Part 1 are:

SI Testss - Part 1

As the test implies, the Supine-to-Sit Test begins in supine with both lower extremities extended. Supine to Sit Test The clinician palpates the medial malleoli to assess leg length (image 1).  While holding the position on the medial malleoli, the patient moves into long sitting (image 2).  Leg length is re-assessed.  Ideally, there should be no relative change.  However, if the malleolus of the involved leg moves distal (gets longer), there may be a posterior ilium rotation.  If the malleolus of the involved leg moves proximal (gets shorter), there may be an anterior ilium rotation.

Prone Knee Bend Test is obviously performed in the prone positioProne Knee Bend 1n wiProne Knee Bend 2th the clinician assessing relative leg length with legs extended (left image).  Both knees are passively flexed to 90° (right image) with leg length reassessed.  Interruption of this test is similar to that of the supine-to-sit test.  A change in leg length is considered a positive test.  If one leg appears shortened in the prone knee extended position and appears to lengthen in the prone knee flexed position, this may imply a posterior innominate rotation.

Gillet March Test has been described to be done using bilateral and unilateral techniquGillet March Testes.
Bilateral: In standing, palpate the inferior aspects of both PSISs as the hip is flexed to 120 degrees
Unilateral: In standing, palpate the inferior aspect of 1 PSIS and sacral base as the hip is flexed to 120 degrees (image).  This can be repeated by palpating the other PSIS and flexing the ipsilateral hip.  Flexion of the hip should result in rotation downward and medial of the ipsilateral PSIS.  A positive test is one of reduced mobility of the ipsilateral PSIS suggesting a reduction of posterior rotation of that innominate. Standing Forward Flexion Test

Standing Forward Flexion Test also begins with palpating the PSIS bilaterally while the patient forward bends.  Movement should be symmetrical.  Asymmetrical movement implies dysfunction on the side that moves first and furthest.

Sit Slump Test

Sit-Slump Test is obviously performed in sitting.  The clinician palpates the bilateral sacral sulci while patient slowly moves from a position of backward bending to forward bending, i.e. erect posture to a slumping posture (image).  Detecting an overall reduction in motion is difficult since there are no normalized standards.  However, asymmetric movement or a reproduction of symptoms is a positive test result.

SI Compression TestThere are 2 tests identified as the decompression and distraction tests and they can be easily confused if one does not understand the physiology of the tests.  The tests are both named for the anterior aspect of the iliosacral junction.  Thus, the compression of the anterior aspect of the iliosacral junction is identified as the SI Compression Test.  Of course, that means the posterior aspect of the iliosacral junction is being distracted (hence the coSI Distraction Testnfusion).  The SI Compression Test (left) can be performed in sidelying or supine.  A force is applied through the lateral aspect of the iliac crest(s).  A positive test is a reproduction of SI joint pain.  The SI Distraction Test distracts the anterior aspect of the anterior iliosacral junction and compresses the posterior aspect.  This test is performed in supine (right).  The clinician applies a lateral force to the ASIS’s through the palms of the hands.  A positive test is reproduction of SI joint pain.

Gaenslen TestGaenslen Test is a maneuver in which 1 knee is brought to the chest while the other leg remains extended.  At end range, overpressure is added.  Thus, imparting torsion to the SIJ.  Additional stress may be applied to the SIJ if the extended leg is placed over the edge of the table.  Again, a positive test is the reproduction of symptoms in the region of the SIJ.

All of the tests discussed are assessing SI mobility via sagittal plane motion or by imparting varying magnitudes of force.  The table below summarizes the metrics of these tests.  Despite having limited motion, some of the tests have relatively strong diagnostic properties.

SI Part 1 Test Statistics

Levangie (1999) reported individual test sensitivities were low (8%-44%), as were negative predictive values (28%-38%), for identifying the presence of innominate torsion in the Gillet, standing forward flexion, sitting forward flexion, and supine-to-sit tests.  With the exception of the Gillet test (odds ratio = 4.57), combining tests did not improve performance characteristics.

On the other hand, sometimes clustering of clinical tests can significantly increase the statistical value.  A good example of this is the combination supine-to-sit, standing forward flexion, sitting PSIS palpation, and prone knee bend tests.  When 3 of 4 tests are positive, the statistics are notably better:

SI Test Clustering

In The Challenge of SI Testing – Part 2, additional SIJ tests will be discussed.   

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