MSK 2 Lab - Week 3 - SIJ

What are the special tests associated with SIJ pain? (7)

Laslet cluster:
-distraction
-thigh thrust
-compression
-sacral thrust
-Gaenslen's test

Faber test

Active SLR test

What is the distraction test that is part of the laslet cluster?

-Patient is supine
-PT applies an A-P force to the patients ASIS

The test is positive with reproduction of symptoms at the PSIS
(this is the most specific test of the cluster)

What is the thigh thrust test that is part of the laslet cluster?

-Patient is supine
-The PT places one hand under the patients sacrum to provide a fulcrum.
-The PT then uses his body/other arm to apply an A-P force along the line of the femur.

The test is positive with reproduction of symptoms at the PSIS.
(this is the most sensitive test of the cluster)

What is the compression test?

-Patient is side lying
-PT places hands in between the iliac crest and the greater trochanter and applies a force directly towards the floor to compress the SIJ

The test is positive with reproduction of symptoms at the PSIS.

What is the sacral thrust test?

-Patient is prone on the table
-PT places the base of the palm on the patients sacral base/S2 and applies a force directly down toward the floor.

The test is positive with reproduction of symptoms.

How many of the laslet test items need to be positive for the cluster to be positive?

2/4 of only doing 4.
or
3/6 if adding the Gaenslens test

What are the statistics for the laslet cluster?

Positive - 35% certainty of having correctly identified SI joint pain

Negative - 92% certainty that a negative test result is correct.

This is why the cluster is good for ruling out but not so much for ruling in and why SIJ pain is a diagnosis of exclusion.

What is the Gaenslens test? And how is it performed?

An SIJ provocation test that can be included in the laslet cluster.

-The patient is supine on the table with one leg hanging off the edge of the table at the knee
-The PT stabilizes the leg against the table while bringing the other leg into maximal hip flexion.
-Overpressure is applied.
-Repeat on both sides

The test is positive with reproduction of concordant pain.

How do you interpret the results of the Gaenslens test?

This test assesses both SI joints at the same time.

-The side with maximal hip flexion is posteriorly rotating the innominate. If this reproduces pain at the SIJ, they are provocative for an anterior rotation.

-The side with hip extension is anteriorly rotating the innominate. If this reproduces concordant pain at the SIJ, they are provocative for an anterior rotation.

What is the FABER test in terms of the SIJ?

Same flexion-abduction-external rotation test but it is positive for the SIJ with reproduction of pain at the PSIS.

What is the active SLR test?

A multistep test to identify SIJ instability once an SIJ pathology has been ruled in. The test consists of 3 parts.
-The first part rules in SIJ instability
-Parts 2 and 3 determine if the patient would benefit from passive stabilization or active stabilization.

How are the three parts of the active SLR test performed?

Part 1:
-patient is supine and performs an active SLR
-patient rates difficulty/pain with each leg
The test is positive with reproduction of concordant pain

Part 2:
-The PT adds bilateral compression to the SIJ (to simulate passive stabilization/form closure)
-With the added compression, the patient re-performs the active SLR
The test is positive if the concordant pain diminished or went away and indicates the patient would benefit from passive stabilization.

Part 3:
-Have the patient perform an active SLR, then crunch up onto an oblique crunch toward the raised leg.
-The PT can apply gentle resistance to increase the muscle contractions
The test is positive if the concordant pain diminished or went away and indicates the patient would benefit from active stabilization.

What special tests would suggest hypomobile SIJ pathology? (3)

Patients who are compression sensitive:
-Faber
-Side lying compression
-sacral thrust

What special tests would suggest hypermobile SIJ pathology? (3)

Patients who are distraction sensitive:
-Thigh thrust
-Distraction test
-Active SLR

What is the decision tree for diagnosis of specific SIJ pathology?

-Fortin Finger Sign
-Clear the lumbar spine
-positive laslet cluster

If laslet suggests compression sensitive:
-Faber test

If positive:
-perform Gaenslens test to determine if the patient is anterior provocative or posterior provocative

If the faber was negative or the laslet suggested distraction sensitive:
-Perform active SLR test to determine if the patient lacks passive or active stability at the SIJ.

If the patient is hypomobile/compression sensitive and is anteriorly provocative, what can be done for treatment?

Mobilize posteriorly

If the patient is hypomobile/compression sensitive and is posteriorly provocative, what can be done for treatment?

Mobilize anteriorly

If the patient is hypermobile/distraction sensitive and lacks passive stability, what can be done for treatment?

passive stabilization, i.e. wear a belt to get the joint to calm down.

If the patient is hypermobile/distraction sensitive and lacks active stability, what can be done for treatment?

Active stabilization exercises.

When performing the laslet cluster what is the recommended order should it be completed in?

-thigh thrust
-distraction test
-compression test
-sacral thrust test

How is an innominate anterior rotation performed?

-The patient is side lying with their top leg in extension and supported on a pillow/foam roller
-The PT places one hand on the PSIS and the other hand on the anterior aspect of the greater trochanter
-The PT then uses both hands to apply an anterior rotary force, like turning a wheel to the innominate.
-assess for R1 and R2, as well as pain provocation.

How is an innominate posterior rotation performed?

-The patient is side lying with their top leg at a 90/90 position and supported on a pillow/foam roller
-The PT places one hand on the ASIS and the other hand on the ischial tuberosity.
-The PT then uses both hands to apply an posterior rotary force, like turning a wheel to the innominate.
-assess for R1 and R2, as well as pain provocation.

If an innominate anterior or posterior rotation is provocative, what can be done for treatment?

The assessment becomes the treatment.

If one direction is provocative, perform a graded mobilization i to the opposite direction with the same technique.

How is an upslip test performed?

-Patient is prone on the table
-The PT places one hand on the sacrum to stabilize and places the other hand on the ischial tuberosity
-The PT then blocked the sacrum while applying a cranial directed force to the ischial tuberosity.
-assess for R1 and R2, as well as pain provocation.

How is a downslip test performed?

-Patient is prone on the table
-PT places one hand at the inferior lateral angle of the sacrum to stabilize and the other hand at the iliac crest.
-The PT stabilizes the sacrum while applying a caudal force to the iliac crest.
-assess for R1 and R2, as well as pain provocation.

If an upslip test or downslip test is provocative, what can be done for treatment?

The assessment becomes the treatment.

If one direction is provocative, perform a graded mobilization i to the opposite direction with the same technique.

What is the general idea behind muscle energy treatment techniques?

Using muscle activation to move the joint.

What is the shotgun muscle energy technique?

A series of isometrics for adduction and abduction completed at different ranges in the ROM.
-Begin with knees bent and close together pushing gently into abduction
-increase the abduction angle and repeat
-increase the abduction angle and repeat
-switch to adduction isometrics with knees wide
-decrease the adduction angle and repeat
-decrease the adduction angle and repeat (like adductor squeeze test.

What is the muscle energy technique to "correct" anterior rotation/dysfunction? (this means anterior rotation is provocative)

-Patient is supine
-Bring the patient's knee up into hip flexion
-have the patient bring the leg down into hip extension and apply resistance to make it an isometric
-increase flexion angle and repeat
-increase flexion angle and repeat

(works to get glute max and hamstring to "bring the joint" anterior)

What is the muscle energy technique to "correct" posterior rotation/dysfunction? (this means posterior rotation is provocative)

-Patient is supine with leg hanging off the table at the knee
-have the patient bring the knee up to the ceiling and apply resistance to make it an isometric.
-Increase the hip extension and repeat
-increaase the hip extension and repeat

(works to get rectus femoris and iliopsoas to "bring the joint" posterior)

Is there any good reason to treat the sacrum itself (such as for a sacral torsion)?

Nope, treat the SIJs and the lumbar spine.

What is the overall goal with diagnosing and treating SI joint pain?

Assess for concordant sign -> treat it -> reassess -> think about what you found again, and move on.

How is a SIJ manipulation performed?

-Patient is supine on the table along the opposite edge.
-Move the patients hips toward you to bring them into a side bend (be sure to instruct them not to follow with their shoulders)
-Adjusts the legs and the shoulders to bring them into max lateral flexion.
-place 1 knee on the table to block the shoulders/trunk from coming out of the side bend.
-have pt place hands behind head
-use the opposite scapula to raise the opposite shoulder.
-thread rostral hand through the patients arm and plant down onto the table to lock the patients spine into position.
-Adjust your body position to take up slack and make sure their opposite ASIS rises off of the table
-Place caudal hand on the ASIS
-Instruct the patient to breath in deeply and breath all the way out and relax.
-Apply the manipulation.