When to Treat the Sacroiliac Joint vs. Lumbar Spine

Many patients present to Orthopedic Physical Therapy clinics with pain in the region of their sacroiliac joint. However, simply because someone has pain in the region of their SI joint does not mean the SI is the cause of their problem. In many instances these patients also have low back pain, hip pain, and/or other neurological symptoms. In this post, I discuss when to focus treatment on the sacroiliac joint versus treating the lumbar spine. 

​When evaluating patients with lumbopelvic issues, I  try to determine if the patient has lumbar dysfunction, SIJ dysfunction, or both. While some sacroiliac joint testing is naturally built into my efficient lumbar exam, the priority of my treatments is based off the lumbar examination findings. A study by Dreyfuss et al states that "patients with confirmed SIJ pain rarely identify concurrent pain at or above L5. (1)"  In other words, individuals with SIJ pain (via anesthetic block) rarely had lumbar spine pain as well. Therefore, if symptoms are reproduced in the lumbar spine during my joint assessment, I will usually start my treatment in this region. 

While the lumbar spine is always a great starting location, I do have other patients with a clear clinical description of SIJ dysfunction. For example, they have unilateral SIJ pain, clear MOI, reported history of hypermobility, etc... After evaluating the lumbar spine, I perform Laslett's cluster for SIJ dysfunction (see tests below). If the patient has 3/5 positive tests, the likelihood of SIJ dysfunction significantly increases (2). Clinically, I do not guide my treatment based off palpation of anatomical landmarks due to significant amounts of anatomical variability. For example, the female pelvis is shaped different than the male pelvis. Additionally, the shape and structure of a child's pelvis is vastly different than an older individual. In support of this rationale, the OCS current concepts on the pelvis and sacroiliac joint state that positional palpation of the SIJ region is 'creative at best.'

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Laslett's Provocation Tests include: 
Compression
Distraction
Thigh Thrust
Sacral Thrust
Gaenslen Test

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In conclusion, patients with lumbopelvic dysfunction may have a lumbar problem, SIJ problem or both. Clinically, if symptoms exist above L5, I treat the lumbar spine first. If symptoms exist above L5 and the patient has >3/5 positive SIJ provocation tests, I treat the lumbar spine and the SI joint. Finally, if there is no lumbar pain and a positive Laslett cluster, I treat the SIJ joint. While the research guides me to the region of dysfunction, my examination and treatment is heavily based on movement analysis and identifying poor movement patterns. Additionally, it must be emphasized that the clinician needs to assess the thoracic spine, hips, and function of the core muscles when evaluating any patient with lumbopelvic dysfunction. 

​-Jim Heafner PT, DPT, OCS

Order of Treatment:
Pain above L5 => Address lumbar spine first
Pain above L5 + Positive Laslett Cluster=> Address lumbar spine and SIJ
No lumbar pain + Positive Laslett Cluster= Address SIJ and primary impairments

References: 
(1) Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bog- duk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996;21 (22):2594-2 602. 

(2) Laslett M, Young S, Aprill C, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J PHysiother 2003;49:89-97

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