L9: Assessment of SIJ and Pelvis Flashcards
SIJ palpation & movement detection tests has ____ (good/poor) inter-examiner reliability and validity.
poor
What are 3 reasons why SIJ palpation & movement detection tests has poor inter-examiner reliability and validity?
- Static SIJ palpation has limited/no utility to identify SIJ structures.
- Hard to find SIJ landmarks
- Hard to diagnose based on movement palpation
SIJ provocation tests have ____ (acceptable/unacceptable) inter-examiner reliability and have clinically useful validity
acceptable
What is a positive test on the SIJ provocation test?
- Dominant pain in SIJ area
- 3 out of 5 positive provocation tests
What are 8 tests that are done in the SIJ physical examination?
- Standing observation
- Gait assessment
- Lumbar ROM (to rule out Lumbar)
- Provocation Tests
- Movement examination
- Palpation
- Test for Active Stability – Active SLR
- Muscle tests
What are 3 things to look at in the standing observation?
- Global posture, lumbar spine &pelvic position, levels of iliac crests, ASIS, PSIS, sacral position, ischial tuberosities, knee creases, scoliosis, gluteal wasting
- Major leg length discrepancy (>2cm)
- Functional task: Ask patient to perform aggravating activity (as long as not too irritable). Similar to LBP observation/exam just focus on pelvis
What are 6 things to look at in gait assessment?
- Most people get SIJ pain in standing-based activities.
- Observe for normal or excessive pelvic rotation during the gait cycle.
- Look for stride and swing length asymmetries
- Load transfer between legs: Observe for Trendelenburg or reverse Trendelenburg
- Ask about symptoms during gait
- Single leg squat/stand/hop
What is something to look at in lumbar ROM assessment?
Rule out lumbar referred pain via lumbar ROM, OP, PAVIM.
What are 3 scenarios to continue an SIJ assessment?
- Patients primary symptoms should be below L5
- Symptoms would be located at or near the SIJ – usually unilateral
- Patient would not have low back symptoms on Lumbar ROM assessment or PAIVMs
- If these things are found on subjective and Lumbar ROM – continue with physical exam (provocation tests) to confirm whether symptoms are arising from the SIJ
Provocation Tests have _____ (high/low) sensitivity and specificity. It is reliable and valid to determine if symptoms are from the ______.
High; SIJ
When is SIJ pain confirmed?
first 2 or ≥3/5 provocation tests are +ve.
What are 5 SIJ provocation tests?
- Thigh Thrust
- Distraction
- Compression
- Sacral PA
- Gaenslens Test
What is the position for a thigh thrust?
1 hand under sacrum. 1 hand push down on flexed leg to shear the pelvis onto sacrum
What is the position for a distraction?
2 hands push down on both ASIS - distract the anterior part of SIJ.
What is the position for a compression?
2 hands push down on iliac crest (sidelye).
What is the position for a sacral PA?
2 hands push down on posterior sacrum. Can move around the sacrum and push.
May bring on L5/S1 LBP
What is the position for a Gaenslens Test?
1 hand flexed hip. 1 hand ext opposite hip.
What are 2 characteristics of the movement examination?
Assess side differences, weight transfer, and symptoms on weight transfer.
Indication for muscle strength and control deficits - informs manual therapy & exercise.
Poor inter-tester reliability, low sensitivity and poor specificity. Too low to determine if SIJ is source of symptoms.
What is the Gillets test hip flexion (movement exam)?
With hip flexion >90° of the tested side, the structures on the posterior pelvis become taught, which posteriorly rotate the innominate relative to the sacrum. With restriction of the SIJ, there is less innominate movement relative to the sacrum.
What are 5 steps (procedure) in the Gillets test hip flexion (movement exam)?
Assesses ipsilateral innominate posterior rotation & transverse rotation.
- 1 thumb on S2. 1 thumb on PSIS.
- Patient hip flex >90° on tested side. During hip flexion, monitor PSIS on the moving side relative to central sacrum (S2): PSIS should move infero-medially relative to the sacrum.
- +ve if decreased PSIS movement compared to other side, PSIS stays same or rises up, or if replicates symptoms.
- May indicate decreased posterior rotation of innominate, or lack of sacral nutation on the tested side.
Can use this to assess weight transfer and identify major side-to-side differences. Quick test!
What is the reliability of the Gillets test hip flexion (movement exam)?
Extremely low reliability, sensitivity and accuracy. Abnormal SIJ movement can be found in asymptomatic patients, so this test should not be used to determine whether symptoms are from the SIJ.
What are 5 steps (procedure) in the Gillets test hip extension (movement exam)?
Assesses ipsilateral innominate anterior rotation & transverse rotation.
- Both hands palpate iliac crest & PSIS.
- Patient hip ext on tested side. During hip extension, monitor PSIS and iliac crest on the moving side relative to central sacrum (S2): PSIS should move up slightly relative to the sacrum.
- +ve if decreased PSIS movement compared to other side
- May indicate decreased anterior rotation of innominate, or lack of sacral counternutation on the tested side.
Can use this to assess any difference or difficulty with weight transfer.
What is the reliability of the Gillets test hip extension (movement exam)?
Low reliability
What are 3 steps (procedure) in the Stork test (movement exam)?
Assesses load transference, lateral rotation and pelvic control, not a test of movements.
- Palpate PSIS &sacrum on WB side
- Watch weight transfer to WB side.
- Monitor PSIS, iliac crest and sacrum on WB side when moving opposite hip into flexion: Sacrum should stay nutated on WB side.
What are 4 findings regarding loading transfer in the Stork Test?
- Excessive shift as goes into single leg stance. Trendelenburg/reverse Trendelenburg
- Sacrum is not in nutation
- Symptoms
What is the reliability of the Stork Test (movement exam)?
Moderate to good inter-therapist reliability
What are 4 characteristics of palpation in prone (movement exam)?
- Palpation after confirmed SIJ pain. Can do this after other prone tests.
- Bony landmarks: PSIS, inferior lateral angle (ILA), sacral sulcus, ischial tuberosity.
- Ligaments
- Muscle tone, tenderness, side differences (hypertrophy?), spasms, symptoms Piriformis, psoas/iliacus, Gmax, latissimus dorsi, multifidus, erector spinae, thoracolumbar fascia.
What is the test for active stability?
Active SLR
What are 6 characteristics of the active SLR?
- Assesses load transfer across pelvis and associated symptoms.
- Tests force closure. Can use on anyone with pelvic pain.
- ASLR has test-retest reliability.
- Patient hip flex 20cm off the bed.
- -ve if patient can lift leg without effort, breathing normal. No pelvic floor descent, no loss of diaphragmatic excursion but some variation in minute ventilation.
- +ve if patient find it easier and less painful with external support &compression.
- Observe compensatory movement & breathing pattern: Bracing reflects muscle strategies - signs of difficulty.
- +ve if the patient cannot do or requires significant effort. Increased intra-abdominal pressure and pelvic floor depression, diaphragmatic splinting and increased minute ventilation.
- Rate the level of difficulty on 6-point scale.
- VAS is ok too.
- Result informs management
- Pregnancy pelvic pain - give brace support
- Normal people - strengthen pelvic muscles
What are the 6 point scale of difficulty?
0 Not difficult at all
1 Minimally difficult
2 Somewhat difficult
3 Fairly difficult
4 Very difficult
5 Unable to do
What are 3 characteristics muscle tests?
- Prioritise - only test key muscles that potentially contribute to the problem
- Symptoms with WB/prolonged walking/higher loading?
- MMT: Transversus abdominis, MF, Gmax/med, hip adductors, pelvic floor, trunk extensors
- Patients with SIJ pain have early onset of biceps femoris, and delayed onset of IO, MF and Gmax on single leg stance on affected side.
- MLT: Piriformis, Hip Flexors, Hamstring
What is the patient position for the piriformis length test?
Supine
Palpate in prone, from superolateral pelvis moving inferomedially.
What is the patient motion for the piriformis length test?
- Hip flex 60°+ internal rotation + adduction + compress femur Hip flex 90-100° + external rotation + adduction + compress femur
- Isometric hold towards hip internal rotation against resistance.
What are 3 measures for the piriformis length test?
- Compare internal/external rotation to normal range.
- Ask for tightness.
- Nervy findings indicate deep gluteal syndrome.
What are 9 features of the physical examination of pubic symphysis pain and groin pain?
- Observation
- Functional tests: Hopping, squat, single leg squat, running (observe lumbo-pelvic control)
- Clear lumbar spine & hip FADIR
- Palpation – include spring test if necessary
- Adductor squeeze test
- Hip ROM: Hip joint restriction may be a risk factor for groin pain, especially for male athletes.
- MMT of key muscles: e.g. Gmed &abdominals
- MLT of key muscles: e.g. piriformis, hamstring, Thomas test
- Active SLR especially if really symptomatic
