special tests for sacroiliac pain
The sacroiliac joint (SIJ) has been estimated to contribute to pain in as much as 38% of cases of lower back pain. There are no clear diagnostic or treatment pathways . The sacroiliac joint (SIJ) is a large, irregularly shaped, serpentine joint structure bordered anteriorly and posteriorly by the sacroiliac ligaments. The joint itself is about two-thirds synovial and one-third ligamentous, with the synovial portion extending anteroinferiorly and reinforced at its posterosuperior aspect by syndesmotic ligament . The form of the SIJ begets its function – it is intended for stability, with a sacral concave depression interlocking with a corresponding iliac osseous ridge. This construct is further reinforced extra-articularly by the sacrospinous and sacrotuberous ligaments. The SIJ complex is part of the kinetic chain connecting the spine and lower extremities, and may be a primary or secondary pain generator depending on the clinical scenario and should be examined routinely in the evaluation of back or leg complaints.
One of the most challenging aspects of diagnosing and treating SIJ dysfunction lies in its inconsistent presentation. SIJ pain can be present through localized and/or referred pain. The most common complaints include pain in the lower back, buttocks, leg, groin, and hip . Symptoms such as increased urinary frequency and transient numbness/tingling have also been reported . The most common areas of referred pain are the buttocks (94 %), lower lumbar region (72 %), lower extremity (50 %), and groin (14 %) . The quality of the pain can range from dull and achy to sharp and stabbing. Aggravating factors include all types of physical activity, unspecified sustained positions, bending, climbing, rising, and sexual intercourse. The most consistent factor for identifying SIJ pain is unilateral pain below L5.
The inconsistent presentation of SIJ pain can be attributed to the presumably extensive innervation of the joint. Several muscle groups become involved, which can result in spasms as a predominant presentation. The most common presentations involving muscle groups include tightness of the hamstrings, quadriceps, and hip flexors.
Common pathologies arising from the SIJ include: sprains, strains and dysfunction of the joint secondary to insufficient or excessive mobility. Factors that increase the risk of these conditions include leg length discrepancy, antalgic gait, scoliosis, and prolonged vigorous exercise. This multitude of triggers, makes low back pain of SIJ origin extremely challenging for the health care provider to clinically diagnose.
SIJ dysfunction diagnosis is based on several clinical criteria including the pain distribution, clinical tests/maneuvers unique to SIJ that reproduce the patient’s exact pain and is usually confirmed by pain relief after intra-articular joint local anesthetic injection. Although there is no gold standard diagnostic test for sacroiliac joint related pain, the intra-articular SIJ injections are being used extensively in the clinical setting as a diagnostic and therapeutic injection. In spite the fact that SIJ injection is not a gold standard test, it is a superior test compared to physical examination. In the absence of gold standard test for diagnosis of SIJ pain, intra-articular injection can be used as a reference test for validation of physical examination.
The five following provocative tests have a high degree of sensitivity and specificity when used in combination. Three or more tests must be positive with at least one resulting from the Thigh Trust or Compression Test. This diagnostic threshold yields a sensitivity of 85% and a specificity of 76% . Testing sequence should be performed in a manner to minimize position changes for patient comfort and may include tests to diagnose comorbid hip pathology.
If the examiner must continue provocative testing to adequately evaluate the SI joint, the patient is asked to lie on the unaffected side with the suspected SI joint facing upward and both hips and knees comfortable flexed. Examiner will stand posterior to the patient at the level of the pelvis. The examiner places one palm between the upward-facing ASIS and greater trochanter and uses the free hand to brace the contacted hand. With the examiner’s elbows fully extended, vertical pressure is applied through the pelvis into the exam table. The test is positive when the patient’s pain is reproduced .
The patient lies supine with the examiner standing next to the patient at or just inferior to the level of the pelvis. Examiner will place each palm on the patient’s ASIS while keeping elbows extended and apply an adequate posterolateral force directed at distracting the SI joints. The test is positive when the patient’s pain is reproduced.
Provocation testing is continued with the patient positioned back to supine and the affected side pelvis laterally displaced toward the edge of the exam table. The patient is asked to maximally flex the unaffected side hip and knee and hold that position using their hands. The examiner will then drape the affected side leg over the side of the examination table moving the hip into an extended position. The examiner will stabilize the flexed extremity with one hand while simultaneously provided gentle downward pressure on the anterior aspect of the extended thigh. The test is positive when the patient’s pain is reproduced.
With the patient still supine and examiner standing on the patient’s affected side, position the ipsilateral leg to 90-degree hip flexion and allow the knee to passively flex. The examiner places one hand on contralateral ASIS to stabilize the pelvis. The opposite hand is then placed on the anterior aspect of the passively flexed knee and vertical pressure is applied posteriorly through the patient’s femur to create a shearing force at the affected SI joint. The test is positive when the patient’s pain is reproduced.
While the patient remains supine, position the affected leg to 90-degree hip and knee flexion. Abduct and externally rotation the ipsilateral leg at the hip joint and rest the lateral aspect of the patient’s calf on the anterior aspect of the contralateral thigh, resembling a figure four. The examiner places one hand on the contralateral ASIS to stabilize the pelvis. The opposite hand applies a gentle posteriorly directed force on the anteromedial aspect of the affected side knee. This test is positive for SI joint pain when the patient describes posteriorly localized pain near the affected side SI joint and can fulfill the three or more requirement for provocation testing. However, if the pain is described anteriorly this may indicate hip pathology as the sole or an additional source of pain contributing to the patient’s presentation. At this point, addition hip special testing (i.e., Scour Test, FADIR Test) can be performed.
Contrasting evidence exists in regards to special tests for sacroiliac pain. Dreyfuss et al., Maigne et al., and Slipman et al. found that history and physical examination play a very limited role in diagnosing SIJ pain [9-11]. Additionally, a systematic review comparing different diagnostic techniques concluded that the evidence for the diagnostic accuracy of sacroiliac joint injections is good, the evidence for provocation maneuvers is fair, and evidence for imaging is limited . Most recently, Schneider et al. tested the diagnostic value of 6 physical examinations in 36 patients and they found no diagnostic value for the physical examination .
Another recent study evaluated the sensitivity and specificity in 200 individuals with sacroiliac pain as the primary diagnosis . Three tests were performed: FABER, thigh thrust and a modified Gaenslen’s test (Mikhail test). The Mikhail tests is done in the lateral recumbent position while flexing and over-extending the hip to stress the SIJ. The test was considered positive if pain was reproduced only with the extreme extension movement and is relieved with the forward flexion movement. Diagnosis was then confirmed with an SIJ injection. The results were similar to the publications of various authors and found that physical examination plays a limited role in diagnosing SIJ pain.
The clinical tests and/or their combinations added no significant predictive capacity compared to patients’ baseline characteristics in predicting the response to diagnostic sacroiliac joint injection, albeit the combinations of Mekhail’s and Patrick’s test yielded high sensitivity (94%). This suggests it would be viable for screening, possibly reducing unnecessary costs of diagnostic SIJ injection procedures .
Table 1. Summary of special test for sacroiliac joint pain. Adopted from .
In summary, sacroiliac joint pain is a significant pathology with a high probability of being observed in cases of lumbar pain. The presence of SIJ pain must be considered in patients with lumbar pain, particularly in the absence of neurological deficit, and care must be taken in treatment decisions in pathologies of the intervertebral disk. Multiple studies have shown inconsistent results in regards to diagnosis with history or single provocative maneuvers. A multitest assessment consisting of a combination of provocation tests exhibited sufficient reliability and validity in the diagnosis of SIJ pain, but the evidence is not strong enough to form a definitive algorithm or gold standard for diagnosis.
- Yoshihara H. Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge. Eur Spine J. 2012;21(9):1788–1796. doi: 10.1007/s00586-012-2350-8
- Tsoi C, Griffith JF, Lee RKL, Wong PCH, Tam LS. Imaging of sacroiliitis: current status, limitations and pitfalls. Quant Imaging Med Surg. 2019;9(2):318–335. doi: 10.21037/qims.2018.11.10
- Sims Vicki, PT. The secret cause of low back pain: how to end your suffering; 2004: pp. 11–12.
- Sembrano JN. How often is low back pain not coming from the back? Spine. 2009;34(1):27–32.
- Slipman CW, Jackson HB, Lipetz JS, et al. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil. 2000;81:334–8.
- Lippitt AB. Percutaneous fixation of the sacroiliac joint. In: Vleeming A, editor. The integrated function of the lumbar spine and sacroiliac joint. Rotterdam: European Conference Organizers; 1995. p. 369–90.
- Szadek KM, van der Wurff P, van Tulder MW, Zuurmond WW, Perez RSGM. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. J Pain. 2009;10(4):354–368. doi: 10.1016/j.jpain.2008.09.014
- Laslett, Mark, et al. “Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests.” Manual therapy 10.3 (2005): 207-218.
- Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996; 21(22):2594-2602.
- Maigne, Jean-Yves, Alain Aivaliklis, Fabrice Pfefer. “Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain.” Spine 21. 1996 ;(16): 1889- 1892.
- Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E. The predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome. Arch Phys Med Rehabil. 1998 Mar; 79(3):288-92.
- Simopoulos TT, Manchikanti L, Singh V, Gupta S, Hameed H, Diwan S, Cohen SP. A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician. 2012 May-Jun;15(3):E305-44.
- Schneider BJ, Ehsanian R, Rosati R, Huynh L, Levin J, Kennedy DJ. Validity of Physical Exam Maneuvers in the Diagnosis of Sacroiliac Joint Pathology. Pain Med. 2020 Feb 1; 21(2):255-260.
- Mekhail N, Saweris Y, Sue Mehanny D, Makarova N, Guirguis M, Costandi S. Diagnosis of Sacroiliac Joint Pain: Predictive Value of Three Diagnostic Clinical Tests. Pain Pract. 2021 Feb;21(2):204-214. doi: 10.1111/papr.12950. Epub 2020 Oct 24. PMID: 32965780.
- Nicolette Harris, D. A. T., Adriana Peña, and Sofia Núñez Rivera. “Best Practices for Clinical Evaluation of Sacroiliac Joint Pain: An Evidence-to-Practice Review.” Clinical Practice in Athletic Training 4.1 (2021).