Zyga

Looking Beyond the Obvious When Evaluating Low Back Pain

Symptoms of refractory SI pain are often very similar to other conditions in the lumbar spine,
especially discogenic or facetogenic pain. Understanding the differences may help
streamline patient exams and ensure the correct diagnosis.

Common Symptoms Of SI Joint Dysfunction

  • Dull ache below L5, often unilateral
  • Deep posterior pain—may radiate into groin or thigh
  • Intolerance with sitting or lying on affected side
  • Pain while climbing stairs or hills

Patient history and risk factors

  • Notable fall, misstep, awkward lifting or twisting
  • Previous lumbar fusion
  • Anatomic variations (e.g. pelvic or leg asymmetry)
  • Female, past pregnancy

When you see the following, the SI joint should be considered as a pain generator:

  • Pain inferior to L5, especially if patient points near the posterior superior iliac spine (PSIS)(Fortin Finger Test)
  • Negative neurological exam
  • Sacral sulcus tenderness on palpation

Three or more positive provocative maneuvers (At least one of the three tests must be the Compression or Thigh Thrust)

A fluoroscopically guided, intra-articular diagnostic injection with greater than 75% relief is recommended to help confirm the diagnosis. A repeat injection provides added confirmation.

SI Joint Provocative Maneuvers

After performing a general back exam to rule out other diagnoses, ask patients to point to the area of their pain. Repeated pointing near the posterior superior iliac spine (PSIS) is considered a positive sign of SI joint dysfunction. Confirm by assessing tenderness of the sacral sulcus on palpation, and then progress to provocative maneuvers.

  • If three or more provocative maneuvers reproduce the patient’s pain (a positive test), the patient is likely to have refractory SI Joint Pain.
  • One of these maneuvers should be compression or thigh thrust.
  • Diagnosis should then be confirmed via SI joint injection.
  • To learn more about performing provocative maneuvers, contact a representative.

Diagnosis of sacroiliac joint disease

Diagnosis of sacroiliac joint pain

Physician performing the FABAR provocative maneuver to diagnose SI Joint Dysfunction

FABER (Flexion, Abduction, External, Rotation) Provocative Maneuver – Tensile force is applied to the anterior aspect of the SI joint.

Compression Provocative Maneuver – A vertically directed force is applied to the iliac crest directed towards the floor, i.e. transversely across the pelvis, compressing the SI joints.

Compression Provocative Maneuver for Diagnosing SI Joint Dysfunction

Image of Thigh Thrust Provocative Test to diagnose SI Joint Dysfunction

Thigh Thrust Provocative Test – The sacrum is fixated against the table with the left hand and a vertically oriented force is applied through the line of the femur directed posteriorly.

Distraction Provocative Maneuver – Vertically oriented pressure is applied to the anterior superior iliac spine directed posteriorly, distracting the SI joint.

Image of the Distraction Provocative Maneuver to diagnose SI Joint Pain

Image of Physician performing Gaenslen Provocative Maneuver to diagnose SI Joint Dysfunction
Gaenslen Provocative Maneuver – The pelvis is stressed with a torsion force by a superior/ posterior force applied to the right knee and a posteriorly directed force applied to the left knee.

Diagnostic Algorithm for Sacroiliac Joint Pain

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