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Diagnostic Algorithm for Sacroiliac Joint Pain
Physical Examination
• Generalbackpainexamtorule-outotherdiagnoses(e.g.McKenzieExamination2,straightlegraise,lumbarMRI)
• SacralsulcustendernessonpalpationandrepeatedpainpointingnearthePSIS(FortinFingerTest)
Provocative Tests3 Seereverse
• Tests:Compression,ThighThrust,FABER,DistractionandGaenslen’s.Validif3ormoretestsarepositive.Atleastonetestshouldbecompressionorthighthrust.
2
SI Joint Dysfunction Suspected
Complaints
• Intolerancewithsittingorlying
• DullachebelowL5,oftenunilateral
• Buttockpain,mayradiatetothigh/groin
• Painworseclimbingstairsorhills
History/Risk Factors
• Fall,misstep,lifting,twisting,MVA
• Previouslumbarfusion
• Anatomicvariations(e.g.leginequality)
• Female,age62,1Postpartum
1
Patient Symptoms
Rule-outs and Red Flags
• Facetjointarthropathy
• Hipjointdysfunction
• Sciatica,discdisruption,stenosis
• Arthritis,spondylarthropathies
• Fractures(e.g.coccyx,insufficiencyfractures)
• Bertolotti’ssyndrome
• Infectionsandtumors
• Entericconditions(e.g.appendix,IBS)
!
Checkpoint
Diagnostic SIJ Block4
• Fluoroscopic-guided,intra-articularinjection
• Posterior-inferiorapproach
• 2.5mlmax,includes0.5mlcontrast
• Repeatinjectionforconfirmation,›75%relief
3
SI Joint Dysfunction Presumed
Conservative Management (›6 months)
• Medications,braces,SIbelts
• Orthotics(e.g.forleginequality)
• Physicaltherapy,manualmanipulation
• TherapeuticSIinjections
Disabling Pain
• WithSIJointDysfunctionconfirmed,andatleast6monthsconservativetherapy,thepatientmaybeacandidateforSIJointsurgeryusingtheSImmetry®system.
4
SI Joint Dysfunction Confirmed
Surgical Arthrodesis
• TheSImmetry®systemallowsfortruearthrodesisofthesacroiliacjoint.5
Disabling Pain
Provocative Tests for Sacroiliac Joint PainThefollowingprovocativetestshaveshowngooddiagnosticvalidityforsacroiliacpainifthreeormoretestsarepositive3.Atleastonetestshouldbecompressionorthighthrust.Thetestsareconsideredpositiveiftheyreproducethepatient’ssamepain.
Compression Test
This maneuver applies compression across the SI joints.
1.Patientislyingontheirsidewithhipsandkneesflexed.
2.Applyadownwardforcetothepatient’siliaccrest.
Thigh Thrust Test
This maneuver applies a sliding/shearing to the SI joint.
1.Patientissupine.
2.Considerplacingahandunderthesacrumforsupport.
3.Applyadownwardforcetoaverticallyalignedfemur.
FABER Test (Flexion Abduction External Rotation)
This maneuver applies a tension to the anterior aspects of the SI joints.
1.Patientissupine.
2.Placethepatient’sfootoftheaffectedsideontheoppositeknee.
3.Placeahandontheoppositeiliaccrest.
4.Applyadownwardabductionforcetothepatient’sknee.
Distraction Test
This maneuver applies a tension to the anterior aspects of the SI joints.
1.Patientissupine.
2.Applyacross-armposteriorlydirectedforcesimultaneouslytobothASIS.
Gaenslen’s Test
This maneuver applies a counter-rotation/torsion to the SI joints.
1.Patientissupine.
2.Oneleghangsofftheexamtable;theotherisbentattheknee.
3.Applyanextensionforcetothehanginglegwhilesimultaneouslyapplyingaflexionforcetothebentleg.
1. DePalma,etal.MultivariableAnalysesoftheRelationshipsBetweenAge,Gender,andBodyMassIndexandtheSourceofChronicLowBackPain.PainMedicine2012;13:498-506.
2. Laslett,etal.Diagnosingpainfulsacroiliacjoints:AvaliditystudyofaMcKenzieevaluationandsacroiliacprovocationtests.AustralianJournalofPhysiotherapy2003Vol.49.
3. SzadekKM,etal.Diagnosticvalidityofcriteriaforsacroiliacjointpain:asystematicreview.TheJournalofPain.2009:10:354-‐368.
4. BogdukN,ed.SacroiliacJointBlocks.In:PracticeGuidelines.SpinalDiagnostic&TreatmentProcedures.SanFrancisco:InternationalSpineInterventionSociety2004:66–85.
5. Rx only. Please review the Instructions for Use for indications, contraindications, warnings and precautions.
Thismaterialisprovidedasaneducationalresource.Refertostandarddiagnosticpublicationsforfurtherinformation.
Fluoroscopically-guidedSIJinjectionimagecourtesyofAdamJ.Locketz,MD,DABPMR.
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