Evaluation of the Sacroiliac Joint
By: Joanne LaRowe
Overview
The sacroiliac joint is one of the most controversial joints in the body. The joint itself has minimal motion; however, over 35 muscles and numerous ligaments attach to the joint and its positioning between the spine and lower extremity makes it difficult to evaluate, diagnosis and treat. To complicate things further, there is currently no “gold standard” for diagnosing sacroiliac joint (SIJ) pain. Without a gold standard available it is difficult to determine the reliability and validity of various tests used to diagnosis this condition. Taking all of this into consideration, I decided to focus my research question and capstone project on the evaluation of the SI joint hoping to assist myself and other students with a way to most accurately diagnosis SIJ pain in the clinic.
Research Question
My original PICO question from our fall Evidence Based II research class focused on the psychometric properties of movement palpation tests and pain provocation tests and their diagnostic utility in the clinic. Here is a copy of the evidence table I created as a part of answering this research question. To sum up my conclusions from my literature search, I found that movement palpation tests are not accurate and do not have high diagnostic utility due to human’s inability to detect this small amount of motion at the joint. Pain provocation tests are more useful and their psychometric properties are stronger when they are used in a group instead of relying on the results of an individual test.
Evaluation
To expand this research question into my capstone project, I wanted to include the full evaluation process for this joint. For my project I created two powerpoint presentations. One is the longer version, which I have added Voicethread to so that anyone can access and listen to the presentation at any time. Here is a link to my Voicethread. This presentation focuses on common subjective complaints, previous history, pain location, palpation, hip ROM, screening to rule out the hip and lumbar spine, SIJ special tests, clinical rules, common malalignments of the joint and advice from an experienced clinician who sees SIJ pain patients routinely. The purpose of this presentation was to include all aspects of the evaluation process in order to assist students/clinicians in making a SIJ diagnosis. If you would like to save a hard copy of the powerpoint without the Voicethread, here is link for it in powerpoint format: presentation.
MSK I Presentation
The shorter version of my powerpoint was presented to the Musculoskeletal I students on February 28th. This powerpoint focused on the psychometric properties of the various special tests and helpful clinical rules that can be used to diagnosis SIJ pain. The purpose of this presentation was to augment their learning regarding the use of the special tests in the clinic. In order to evaluate my presentation, I asked all of the students and people in attendance to fill out an evaluation form. The summary of my scores and feedback are complied in this word document.
Additional Resources
In addition to the Voicethread I created a handout and a flow chart that follow the powerpoint presentation. The handout is a list of the special tests that were presented in the powerpoint with corresponding pictures to aid the student/clinician. I decided to take my own pictures so that I could accurately depict each of the screening and special tests. The flow chart shows the order that should be followed to accurately diagnosis SIJ pain. If you use my handout or flowchart or access my Voicethread, please fill out this evaluation form to provide me with feedback on my project. You can email it to me at ljoanne@email.unc.edu
Acknowledgements
Although the sacroiliac joint is complex and confusing, I hope these materials will provide you with some additional resources to aid in the evaluation process. I would like to give a big thank you to Barbara Green and Christine Hellinger for assisting me with this project. I would also like to thank Mike Gross, Mike McMorris and Karen McCulloch for their input and feedback throughout the project. A final thank you to Nick Mang and Lorna Troost who are two 1st year students that assisted me with the pictures you see in the powerpoints and handout.
7 Responses to “Evaluation of the Sacroiliac Joint”
Mike Gross
joanne- very nice job with your end products as well as taking feedback and responding to it appropriately and effectifely during the development of this project. Mike Gross
Sarah Yancey
Thanks so much for clarifying Joanne, that helps a lot! Great job on your project; it’s awesome!!
ljoanne
Thank you guys for all of the excellent feedback. I hope the handout and flow chart are helpful during your rotations and in the clinic.
Sarah,
To answer your question, I have not had a lot of experience in the clinic with SIJ patients. The majority of my information comes from research studies and my clinical mentor.
The specific study you referenced by Laslett et al, was a tricky one during the 1st years presentation as well. If all 5 tests are positive, I would definitely not “rule out” the SIJ. This means that the patient demonstrates a high level of pain and any pressure to the area would cause a positive test, so therefore it means that these tests are no longer specific to the SIJ. Although they are not specific, I would still not completely rule it out since the patient does have some cause for the large amount of pain in the area.
It is important to remember that these tests stress a lot of different structures at once, which is one of the reasons for their low psychometric properties. In a patient like you mentioned, I would complete a further detailed palpation assessment of the muscles and ligaments to determine if I can find a more specific cause of the pain since those tests are no longer specific.
Great question and unfortunately, like a lot that is related to the SIJ, there is no straight answer. 3 out of 5 tests is ideal and would move SIJ pain higher up my possible list of diagnoses, but 5 out of 5 would definitely not completely take the SIJ off the list.
I hope that helps!
Joanne
Sarah Yancey
Joanne,
Great work on your project! I think you did a very thorough job of compiling the vast amount of literature on the SI joint. I have been interested in the SI joint ever since I gave an inservice on the topic during my first rotation at an orthopedic outpatient clinic. For my inservice I particularly focused on the poor diagnostic quality of the SIJ movement tests. However, I think you did an excellent job of describing better alternatives to the movement tests and giving a systematic outline for evaluating a patient with suspected SIJ dysfunction. I was particularly impressed with the flow chart. As a student, I love utilizing flow charts to help me know where to start an evaluation and what to do with specific findings.
In your VoiceThread I was especially surprised to see that Laslett et al found that when all of the provocation tests are positive, the SIJ as a source of pain can be ruled out because the tests are no longer specific to the SIJ. Have you ever had experience with a patient who was positive on all five tests or read case studies of patients who were positive on all five and still had SIJ dysfunction? During my first rotation, I saw a patient who was positive on all five tests and was treated for SIJ dysfunction. With muscle energy techniques and core stabilization exercises, the patient’s symptoms significantly improved. Considering your other research and experience, would you recommend completely ruling out the SIJ if they were positive on all five tests? If not, what would your next step be if you had already ruled out the lumbar spine and hip? Just wondering your thoughts on this particular piece of information!
I am so impressed with all your products and will definitely have them handy for my last rotation and future clinical practice. As you said in your overview, the SIJ is one of the most controversial joints in the body, but you did an excellent job synthesizing the information and making it useful for current students and practicing clinicians. Thanks for all your hard work!
Sarah
Donna Dean
Joanne,
Your PowerPoint presentation was phenomenal! As Alex mentioned, it is obvious the vast amount of time you put into this project. The personalized pictures are great, it gave me a clear sense of positioning for special tests and some of the pictures are MUCH better than what is in our textbooks. The first years were lucky to have had your presentation because I must admit, I used your PowerPoint and handout to assist me for a recent assignment. This will certainly be material that I will refer to for all patients with suspected SIJ dysfunction.
The flow chart you provided from multiple resources is such a great tool to have when evaluating patients with non-specific LBP. It is easy to follow and paints a clear picture of steps to follow when suspecting SIJ dysfunction. I cannot imagine how long that must have taken to put together! The handout is also impressive and something I will definitely print out and keep with me throughout my next clinical rotation in outpatient ortho. I have realized how easy it is to forget special tests after studying for the comprehensive exam and you have provided an excellent refresher on the SIJ.
Your section based on “advice from an experienced clinician” was a great reminder on what you will find with a posteriorly/anteriorly rotated innominate, upslip/downslip, and outflare/inflare as I find these can become easily confused in your head. Excellent work and I cannot think of a single thing to suggest you might add or change to this project!
Donna
ljoanne
Sorry about that! I think I got it fixed so everyone can now see it. Let me know if you still have problems accessing the Voicethread. Thanks for letting me know.
Joanne
Alexandra Smith
Hi Joanne,
Awesome job on your project! I can tell that you put a great amount of time and effort into your Capstone. I read over your Powerpoint, but unfortunately I was unable to access your Voicethread. When trying to access it, it denies me and says “You do not have access to this Voicethread, please contact its creator to request permission to view it.” I would LOVE to listen to it when that gets sorted out. 🙂
Reviews from your presentation are great! It definitely seems like the first year students got alot out of it. Your handout is an AWESOME clinical tool that I will most definitely utilize. I REALLY like how you included pictures to go along with the descriptions. Your flow chart is pretty awesome too.
Thanks for the wonderful info!