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When to Treat the Sacroiliac Joint vs. Lumbar Spine

10/12/2016

3 Comments

 
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.'


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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3 Comments
Michael Giardina
10/14/2016 10:25:32 am

This is so helpful!

Reply
Jim link
10/14/2016 07:10:30 pm

Thank Michael. Appreciate it! Glad it can help

Reply
Glenn
10/15/2016 09:39:24 pm

Thanks Jim great post!

I recognize that every client and treatment is completely individualised for effectiveness and safety concerns, but have you found a manual therapy tx (joint mobs, manipulations, MWM, Mckenzie, soft tissue etc.) that is particularly more effective than others in that lumbar region?

Thanks!

Glenn

Reply



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  • Home
  • About Us
  • Insider Access
    • About Insider Access
  • Online Courses
    • Hooper's Knee
    • Physical Therapist Entrepreneur Course
    • Physical Therapist Consultant Course
    • Orthopedic Management of the Cervical Spine
    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test