L9: Assessment of SIJ and Pelvis

Question 1

SIJ palpation & movement detection tests has ____ (good/poor) inter-examiner reliability and validity.

Answer 1

poor

Question 2

What are 3 reasons why SIJ palpation & movement detection tests has poor inter-examiner reliability and validity?

Answer 2

1. Static SIJ palpation has limited/no utility to identify SIJ structures.
2. Hard to find SIJ landmarks
3. Hard to diagnose based on movement palpation

Question 3

SIJ provocation tests have ____ (acceptable/unacceptable) inter-examiner reliability and have clinically useful validity

Answer 3

acceptable

Question 4

What is a positive test on the SIJ provocation test?

Answer 4

• Dominant pain in SIJ area
• 3 out of 5 positive provocation tests

Question 5

What are 8 tests that are done in the SIJ physical examination?

Answer 5

1. Standing observation
2. Gait assessment
3. Lumbar ROM (to rule out Lumbar)
4. Provocation Tests
5. Movement examination
6. Palpation
7. Test for Active Stability – Active SLR
8. Muscle tests

Question 6

What are 3 things to look at in the standing observation?

Answer 6

1. Global posture, lumbar spine &pelvic position, levels of iliac crests, ASIS, PSIS, sacral position, ischial tuberosities, knee creases, scoliosis, gluteal wasting
2. Major leg length discrepancy (>2cm)
3. Functional task: Ask patient to perform aggravating activity (as long as not too irritable). Similar to LBP observation/exam just focus on pelvis

Question 7

What are 6 things to look at in gait assessment?

Answer 7

1. Most people get SIJ pain in standing-based activities.
2. Observe for normal or excessive pelvic rotation during the gait cycle.
3. Look for stride and swing length asymmetries
4. Load transfer between legs: Observe for Trendelenburg or reverse Trendelenburg
5. Ask about symptoms during gait
6. Single leg squat/stand/hop

Question 8

What is something to look at in lumbar ROM assessment?

Answer 8

Rule out lumbar referred pain via lumbar ROM, OP, PAVIM.

Question 9

What are 3 scenarios to continue an SIJ assessment?

Answer 9

1. Patients primary symptoms should be below L5
2. Symptoms would be located at or near the SIJ – usually unilateral
3. 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

Question 10

Provocation Tests have _____ (high/low) sensitivity and specificity. It is reliable and valid to determine if symptoms are from the ______.

Answer 10

High; SIJ

Question 11

When is SIJ pain confirmed?

Answer 11

first 2 or ≥3/5 provocation tests are +ve.

Question 12

What are 5 SIJ provocation tests?

Answer 12

1. Thigh Thrust
2. Distraction
3. Compression
4. Sacral PA
5. Gaenslens Test

Question 13

What is the position for a thigh thrust?

Answer 13

1 hand under sacrum. 1 hand push down on flexed leg to shear the pelvis onto sacrum

Question 14

What is the position for a distraction?

Answer 14

2 hands push down on both ASIS - distract the anterior part of SIJ.

Question 15

What is the position for a compression?

Answer 15

2 hands push down on iliac crest (sidelye).

Question 16

What is the position for a sacral PA?

Answer 16

2 hands push down on posterior sacrum. Can move around the sacrum and push.

May bring on L5/S1 LBP

Question 17

What is the position for a Gaenslens Test?

Answer 17

1 hand flexed hip. 1 hand ext opposite hip.

Question 18

What are 2 characteristics of the movement examination?

Answer 18

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.

Question 19

What is the Gillets test hip flexion (movement exam)?

Answer 19

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.

Question 20

What are 5 steps (procedure) in the Gillets test hip flexion (movement exam)?

Answer 20

Assesses ipsilateral innominate posterior rotation & transverse rotation.

1. 1 thumb on S2. 1 thumb on PSIS.
2. 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.
3. +ve if decreased PSIS movement compared to other side, PSIS stays same or rises up, or if replicates symptoms.
4. 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!

Question 21

What is the reliability of the Gillets test hip flexion (movement exam)?

Answer 21

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.

Question 22

What are 5 steps (procedure) in the Gillets test hip extension (movement exam)?

Answer 22

Assesses ipsilateral innominate anterior rotation & transverse rotation.

1. Both hands palpate iliac crest & PSIS.
2. 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.
3. +ve if decreased PSIS movement compared to other side
4. 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.

Question 23

What is the reliability of the Gillets test hip extension (movement exam)?

Answer 23

Low reliability

Question 24

What are 3 steps (procedure) in the Stork test (movement exam)?

Answer 24

Assesses load transference, lateral rotation and pelvic control, not a test of movements.

1. Palpate PSIS &sacrum on WB side
2. Watch weight transfer to WB side.
3. Monitor PSIS, iliac crest and sacrum on WB side when moving opposite hip into flexion: Sacrum should stay nutated on WB side.

Question 25

What are 4 findings regarding loading transfer in the Stork Test?

Answer 25

1. Excessive shift as goes into single leg stance. Trendelenburg/reverse Trendelenburg
2. Sacrum is not in nutation
3. Symptoms

Question 26

What is the reliability of the Stork Test (movement exam)?

Answer 26

Moderate to good inter-therapist reliability

Question 27

What are 4 characteristics of palpation in prone (movement exam)?

Answer 27

1. Palpation after confirmed SIJ pain. Can do this after other prone tests.
2. Bony landmarks: PSIS, inferior lateral angle (ILA), sacral sulcus, ischial tuberosity.
3. Ligaments
4. Muscle tone, tenderness, side differences (hypertrophy?), spasms, symptoms Piriformis, psoas/iliacus, Gmax, latissimus dorsi, multifidus, erector spinae, thoracolumbar fascia.

Question 28

What is the test for active stability?

Answer 28

Active SLR

Question 29

What are 6 characteristics of the active SLR?

Answer 29

1. Assesses load transfer across pelvis and associated symptoms.
   
   • Tests force closure. Can use on anyone with pelvic pain.
   • ASLR has test-retest reliability.
2. Patient hip flex 20cm off the bed.
3. -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.
4. +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.
5. Rate the level of difficulty on 6-point scale.
   
   • VAS is ok too.
6. Result informs management
   
   • Pregnancy pelvic pain - give brace support
   • Normal people - strengthen pelvic muscles

Question 30

What are the 6 point scale of difficulty?

Answer 30

0 Not difficult at all

1 Minimally difficult

2 Somewhat difficult

3 Fairly difficult

4 Very difficult

5 Unable to do

Question 31

What are 3 characteristics muscle tests?

Answer 31

1. Prioritise - only test key muscles that potentially contribute to the problem
   
   • Symptoms with WB/prolonged walking/higher loading?
2. 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.
3. MLT: Piriformis, Hip Flexors, Hamstring

Question 32

What is the patient position for the piriformis length test?

Answer 32

Supine

Palpate in prone, from superolateral pelvis moving inferomedially.

Question 33

What is the patient motion for the piriformis length test?

Answer 33

• 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.

Question 34

What are 3 measures for the piriformis length test?

Answer 34

• Compare internal/external rotation to normal range.
• Ask for tightness.
• Nervy findings indicate deep gluteal syndrome.

Question 35

What are 9 features of the physical examination of pubic symphysis pain and groin pain?

Answer 35

1. Observation
2. Functional tests: Hopping, squat, single leg squat, running (observe lumbo-pelvic control)
3. Clear lumbar spine & hip FADIR
4. Palpation – include spring test if necessary
5. Adductor squeeze test
6. Hip ROM: Hip joint restriction may be a risk factor for groin pain, especially for male athletes.
7. MMT of key muscles: e.g. Gmed &abdominals
8. MLT of key muscles: e.g. piriformis, hamstring, Thomas test
9. Active SLR especially if really symptomatic