Paradigm for SIJ Assessment

If your experience of learning sacroiliac joint mechanics, testing, and treatment has been confusing at times, trust that you are not alone in this confusion. As students have emerged from training and coursework using a variety of models to understand the joint and surrounding structures, no wonder there is disagreement and inconsistency in clinical application of learned skills. Add to this the many names for a maneuver such as the one leg standing test, and we see that the more we can streamline updated clinical knowledge and practices, the better for our profession and for our patients. I recently enjoyed reading an article summarizing assessment and treatment of sacroiliac joint (SIJ) mechanical dysfunction by Dr. Manuel Cusi, who completed a PhD thesis regarding the joint. In the article, Dr. Cusi summarized a great deal of research-based concepts related to testing and treating this issue.

Although the structure and purpose of the sacroiliac joint are described as "controversial", the author points out the foundational concept that too much or too little stability within the SIJ can create dysfunction. The "self-bracing" mechanism is provided in the pelvic girdle via both form and force closure, and Dr. Cusi points out that this joint stability that is the aim of the self-bracing mechanism must be responsive to each specific loading condition, as a function of gravity, and with coordination of muscle and ligament forces. Also according to the article, in order to assess the SIJ, the focus must be on function rather than solely on anatomic pathology.

Mechanical testing is described as being generally divided into pain provocation or palpation tests. Although we can say, based on the literature, that no one SIJ test can provide reliable data, a cluster of several tests that are positive can provide meaningful information towards a diagnosis. In order to test various aspects of SIJ function, the following tests are listed in the paradigm model. A working knowledge of the tests below, as well as pelvic joint stability tests should comprise the clinician's "toolbox" of tests for the sacroiliac joint, and this is in addition to skills used for determining other causes of SIJ pain such as disease processes or referred symptoms.

•Posterior pelvic pain provocation test (or thigh thrust)
•Long dorsal sacral ligament palpation
•Trendelenburg test
•Stork test (or Gillet test)
•Active straight leg raise (ASLR)
•Patrick's FABER and Gaenslen's test

In relation to treatment approaches, exercise training is recommended as being divided into three stages: isolation (recruiting targeted muscle in isolation of other groups), combination (muscles are recruited in various combinations to develop endurance), and function (utilizing good technique once progressed to meaningful functional tasks). While this flow of exercise training may appear very logical, the author offers that failure to progress through these three phases may be due to several factors such as poorly designed exercises that lack specificity, progressing through exercises before patient has sufficient endurance, poor adherence, and lack of appropriate exercise technique. These factors are described in the article as intrinsic to the exercise program, whereas an extrinsic factor may be failure of the exercise program to work well because of poor ligamentous stability. In this case, the author further describes the therapeutic option of prolotherapy, which will be discussed in an upcoming post.

If you are interested in learning more about the above special tests or about treatment progressions based on technique and integration, check out Peter Philip's Sacroiliac Joint and Pelvic Ring Evaluation & Treatment. The next opportunity to take the course is in January in Seattle.