Like many aspects of diagnostic testing and most in musculoskeletal physiotherapy very few tests are definitive taken in isolation and the current trend is to use clinical prediction rules which group a number of tests in order to confirm or refute positivity. This allows the examiner to conclude with greater confidence when a group of tests are positive even in the presence of some non-positive tests.

Assessment of sacroiliac dysfunction – Foundations.

1. Active straight leg raise test.

2. Pain provocation test.

3. Kinetic tests.

4. Positional assessment.

5. Leg-length tests.

6. Passive movement assessment.

In previous posts I have discussed the role of positional assessment and Leg length testing in relation to mechanical assessment of the pelvic girdle. Today we will focus our discussion on the kinetic tests as they have been formally described. Several renowned authors have written on this topic over the years the most notable being Philip Greenman (an osteopath), Diane Lee (Canadian physiotherapist), Richard DonTingy (US physiotherapist) and Howard Turner (Australian Physiotherapist)  referred to above who has been conducting courses in the British Isles and internationally for the last 15 years on this topic.

Kinetic Tests

Forward Flexion in standing / sitting.

Hip Extension in standing.

Hip Flexion in standing (Stork / Fowler / Guillet Test).

Lateral Flexion in standin.

Rotation in standing / sitting.

When interpreting Kinetic tests it is important to recognize that the evidence of dysfunction does not infer a mechanism of pathology.

The pathology may lie in the articular system, the myofascial system.

The pathology may be local to the pelvic girdle and sacroiliac joint.

The pathology may be secondary to lumbar spine or general postural alignment characteristics

The interpretation of “positivity” is based on the extent of variance from expected norms and the number of positive tests.

The selection of legitimate targets for intervention is based on the degree of deviation on the kinetic tests rather than the side of dominant pain.

Those of you who treat the sacroiliac joint dysfunction frequently are well aware of the propensity of this joint to demonstrate alternating sides of symptoms which can sometimes leave a therapist “chasing pain” rather than identifying primary underlying mechanisms.

1. Forward Flexion in standing

Therapist : palpates inferior aspect of PSIS inferiorly

Patient : flexes forward to end of range.

Normal : PS IS move symmetrically bilaterally

Dysfunction: asymmetrical movement of PS I S. which may be early or late in the movement pattern or the PS I S. moves more Cephalad on flexion

2. Hip extension in standing

Therapist: palpates the idiom and sacrum on one sacroiliac joint.

Patient : extends the hip.

Normal: the PS I S raises cephalad relative to the sacrum

Dysfunction: PS I S. and sacrum move together

3. Hip Flexion in standing (Stork / Gillet / Fowler tests)

Therapist: palpates Ilium and sacrum of one SI joint

Patient: flexes they hit to 90° flexion.

Normal: PS I S. drops caudad relative to sacrum

Dysfunction: increased or decreased movement of Ilium relative to sacrum

4. Rotation in standing

Therapist: palpates Ilium and adjacent sacral segment.

Patient: rotates their torso.

Normal: sacrum lifts relative to PS I S.

Dysfunction: increased or decreased movement of sacrum relative to ilium

PS : the trunk  should rotate to the side of the tested S.i. joint.

5. Lateral flexion in standing

Therapist: palpates Ilium and sacrum of one SI joint.

Patient: performs lateral flexion.

Normal: PSIS drops and sacrum lifts on the side to which lateral flexion occurs

Dysfunction: increased or decreased movement of Ilium relative to sacrum

Clinical Thoughts?

1. Why does the Ilium move cephalad in standing flexion?
2. Why does the ilium move inferiorly relative to the sacrum in Gillet test?
3. How does the coupling of motion occur between Lumbar spine, Sacrum and Ilium in trunk rotation?
4. How do the pelvic biomechanics in lateral flexion occur ie how is the coupled motion achieved?

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2010. | Permalink | One comment | Add to del.icio.us
Post tags: Anatomical terms of location, Conditions and Diseases, Diane Lee, Health, Howard Turner, Kinetic tests, Lumbar vertebrae, pelvic girdle dysfunction, pelvis, Philip Greenman, Physical therapy, Richard DonTingy, sacroiliac, Sacroiliac joint, Sacrum, SI Dysfunction

Feed enhanced by Better Feed from Ozh

The sacroiliac joint has now been well established to actually move yet clinicians of my generation and older would certainly be aware of the argument that the sacroiliac joint did not normally move except in pregnancy.  Suffice to say that we have now moved beyond this argument for the normal population and the clinical challenge is diagnosing not only the existence of sacroiliac dysfunction but the mechanism behind the dysfunction.

Radiological imaging does not particularly add to the diagnostic work-up so we are left to rely on clinical assessment.  In the last decade Vleeming and Schneider’s have advanced the concept of both “form and force closure” as the primary mechanisms maintaining sacroiliac stability.

Form & Force Closure

In brief, form closure refers to the configuration of the joint surfaces, the alignment of these surfaces relative to gravity and bodyweight, and the tension in the restraining ligaments associated with normal alignment of the segments.

Force closure refers to the interaction of multiple muscle groups, which act across the joint to enhance compression on the joint surface to assist in joint stability.  This is the so-called oblique sling system, which has been conceptualised to involve the ipsilateral Glueteus Maximus and Tensor Fascia Lata in conjunction with the contra lateral latissimus dorsii.  This is enhanced anteriorly by the oblique abdominal system and the contra-lateral hip adductors.

These two oblique systems effectively form an X  (cross shape) on the anterior and posterior aspects of the pelvis and constitute the dynamic mechanism by which joint integrity is maintained.  These concepts appear to hold some clinical validity and have provided an enhanced framework for us to approach our treatment of the sacroiliac joint.

Lee has integrated this approach with some of the traditional osteopathic models to provide a clinical algorithm for determining sacroiliac dysfunctions. This involves evaluation of:

1)      Lumbar spine

2)      Pelvic landmarks,

3)      Sacral landmarks.

This provides a practical framework where we as clinicians can try to differentiate primary or secondary pelvic dysfunction and therefore target our treatment in the most appropriate way.  Because of the functional interaction of body segments a lumbar scoliosis, for example, can have secondary effects on the sacroiliac joint alignment and conversely sacroiliac mal-alignment may produce secondary scoliosis in the lumbar spine.  This is the classic “chicken and egg” scenario.

So using the above categorisations we can quantify spinal alignment using:

Visual observation

Palpating bony landmarks

Correlating with movement pattern in the lumbar spine.

Looking specifically at the pelvis we can define the position of the bony landmarks on the pelvis using:

ASIS,

PSIS

Ischial tuberosities

as reasonably reliable landmarks to assess the positional orientation of these bones.

The spectrum of pelvic dysfunctions which have been described include:

Anterior innominate rotation

Posterior innominate rotation

Innominate inflare

Innominate outflare

Innominate upslip

Innominate downslip.

Much debate exists regarding the reliability and mechanism of these syndromes so it is largely a clinical diagnosis.

The principle assumption of quantifying bony pelvic orientation is that the pelvic position will determine the position of the sacrum and therefore mal-alignments of the pelvis should be prioritised over sacral mal-alignments when they are observed to co-exist.

Corrective Measures

In general the principles of correction are either to use manipulative thrust procedures, joint mobilisation or muscle energy / myofascial techniques to help to realign the pelvic structures using the leverage of the torso or lower limbs.  This then leaves us in a situation of assessing the sacral position within the corrected pelvic rim and then ascertaining the sacral orientation. A number of sacral dysfunctions have been categorised.

These include:

1)      Nutated sacrum

2)      Counter- nutated sacrum

3)      Oblique axis twist indicating a spinning mechanism where one side of the sacrum lies deep and the other lies more superficial.

Assessing sacral position within the pelvis is challenging clinically, produces more inter-tester variability and is harder to be confident with.  However it is well worthwhile using this clinical algorithm to define  joint mal-alignments clinically and plan treatment strategies.

Crossing the first hurdle of defining the dysfunction the challenge is then to determine why mal-alignments have occurred and whether we can assess breakdowns in functional control (force closure mechanisms) which may be associated with overload- but that’s another day’s work and a discussion for another time

.

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | No comment | Add to del.icio.us
Post tags: Anterior innominate rotation, form & force closure, Innominate downslip, Innominate inflare, Innominate outflare, Innominate upslip, Posterior innominate rotation, sacroiliac, sacroiliac joint dysfunction, sacroiliac strain, vleeming

Feed enhanced by Better Feed from Ozh