Challenges of SI Testing: Part 2

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Challenges of SI Tests:  Part 2

In The Challenge of SI Testing – Part 1, eight sacroiliac joint (SIJ) tests were discussed. In The Challenge of SI Testing – Part 2, six additional tests will be discussed with statistical data regarding their clinical use.  The six SIJ tests in Part 2 are:SI Test LIstFlare Test

The first 2 SIJ tests are performed in standing.  The Flare Test begins by palpating the PSIS.  The patient is asked to externally and internally rotate his/her hip with the foot on the ground.  The clinician is looking for asymmetrical motion of the PSIS or a reproduction of symptoms to deem the test positive.

Weight Shift TestThe Weight Shift Test also is performed in standing while palpating bilateral PSIS.  Again, the motion is compared when the patient shifts his/her weight from side to side.  A positive test is reproduction of symptoms & increased/decreased mobility compared to the uninvolved side.Resisted Abduction Test

The Resisted Abduction Test is performed in supine in 30 degrees of hip abduction.  The clinician simply resists active hip abduction.  Reproduction of pain over the SI joint is considered a positive test.

Thigh ThrustFor the Thigh Thrust or Posterior Shear (PoSh) Test, the clinician stands to the side of the patient supporting the hip in flexion, slight abduction, and ER.  The clinician then applies a force through the long axis of the femur.  Some clinicians opt to allow the knee on the testing leg to flex (unsupported) and use the other hand to stabilize the opposite pelvis with pressure on the contralateral ASIS.  Reproduction of well localized pain over the ipsilateral gluteal region/SI joint is a positive test.   This test has been reported to be negative in the presence of a lumbar herniated disc.Mennell Test

Mennell Test is performed while sidelying on the involved side. The uninvolved lower extremity is extended and the involved hip/knee is flexed towards the chest.  The clinician stands behind the patient and places 1 hand on the involved posterior pelvic crest/buttocks and other hand on involved knee in order to push involved leg into extension.  A positive test is the reproduction of pain.

FAbER TestFAbER Test uses the acronym FAbER to describe the position of the test: Flexion, Abduction, and External Rotation.  In supine, the patient is placed in the FAbER position (also known as the figure-4 position).  The contralateral pelvis is stabilized and overpressure is applied to the flexed knee.  There are numerous structures that could potentially be incriminated.  Pain assuming the position could be from the sartorius.  Pain with over-pressure could be from the hip or the SI/LB.  If the knee is more than 4 cm from surface, there may be a labrum problem.

For the 6 tests discussed in The Challenge of SI Testing – Part 2, the chart below displays the statistical data.SI Test Part 2 Statistics

As stated in Part 1, 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 summary, the tests for the SIJ are very challenging.  The ability to make an accurate diagnosis can be hampered by tests with high variability in their interpretation.  The current ‘gold standard’ for diagnosing sacroiliac pathologies is a diagnostic nerve block.  This is an injection of an anaesthetic inserted into the SIJ, under fluoroscopy guidance.  However, there are risks in this technique.  Thus, without high quality evidence for a multi-test regimen of sacroiliac joint tests, the challenge remains.

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