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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