This is the last part of the series for sacroiliac joint diagnosis. Refer back for prior posts.
-Part 2 here on pain referral sites.
-Part 3a here for painful palpation sites.
Along the lines of needing painful sites, you need to be able to rule-out other conditions with non-painful palpation and maneuvers to “finalize” SIJ as provocator.
1. Negative SCOUR Test.
-Rule out the hip by performing the SCOUR test.
-No pertinent sensitivity or specificity values but used often as a screen.
2. Negative repeated movement tests; in extension, flexion, or side-bending.
-Studies vary on if lumbar spine structures, such as a disc, need to be ruled-out first prior to performing the multi-test regimen provocation tests.
-Out of the two main studies for this posting, Van der Wurff says no and Laslett says yes.
-Gutke 2009 showed that you do NOT need to rule-out a disc prior to performing PPPP test due to the test still being negative in patients with lumbar disc herniation.
-Some argue that pain cannot be centralized if arising from SIJ.
-Clinically, I don’t do this unless I feel it is necessary based on subjective history.
3. Minimal to no pain to structures above L5 through P/A assessment of lumbar spine.
-Even though the SIJ has close anatomical ties to the erector spinae, facet joints and discs of lumbar spine and thoracolumbar fascia; I feel true SIJ involvement doesn’t cause significant irritation beyond L5 cephalically. If there are painful structures, it is usually much less in intensity than the long dorsal ligament.
-Also, to go back to post #2, most of pain referral sites from SIJ are below L5.
-Out of the 3 actions listed here, I feel this is the most concrete for SIJ involvement.
I feel that to be “certain”, it is appropriate to rule-out the hip and lumbar spine as this does not leave any rocks unturned. Do you agree?
Overall, what is your impression of the 3 part series for diagnosing SIJ pain? Does this fit into what you see clinically?
Gutke et al. 2009. Posterior Pelvic Pain Provocation Test is negative in patients with lumbar herniated discs. Eur Spine J. 18(8): 1109-16.