Vicki Sims, P.T.

Alan Lippitt, M. D.

David Mesnick, P.T.

 

Introduction

Lower back pain (LBP) is a 50 billion-dollar per year growth industry in our society (Graves et al, 1990).  The frequency of back pain is such that in the United States alone there are seven million people off work because of it at any one time.  In fact, the most common cause of occupational disability is, indeed, lower back pain (McKenzie, 1981).

While there has been considerable research directed toward identifying the etiology of LBP, only syndromes that are associated with neurologic compression of the nerve roots are well understood by clinicians.  It has been estimated that a precise diagnosis is unknown in 80-90% of patients with LBP (Richardson and Inglarsh, 1994).

An area of LBP that has attracted increased interest is the sacroiliac joint (SIJ) and its associated structures.  The symptomatology and “syndrome” associated with SIJ has very seldom been addressed by standard orthopedic literature.  The SIJ can often be overlook as a source of chronic lower back pain.  The symptoms associated with SIJ dysfunction are often confused with those of a disc derangement (Stanhope and Onesti, 1999).

In the author’s experience, a significant number of patients diagnosed with SIJ dysfunction follow a specific symptomatology, which differs from other low back pain syndromes.  The objective of this study was to identify several common symptoms that are specifically intensified when the dynamic kinetic chain of the lumbo-pelvic system is no longer a stable platform for force transmission.

Study Design

One-hundred patients who were undergoing physical therapy for sacroiliac instability were sampled prior to a six-week course of treatment.  Patients who had undergone prior back surgery were excluded.  Patients with a known diagnosis of SIJ dysfunction were included in the study.  Each patient was sampled once following a comprehensive evaluation and prior to physical therapy intervention.  Results were taken as a percentage of their reported frequency.

Methods

The authors devised an evaluation form for questioning prior to any physical therapy treatment (see Figure 1).  The patients chose their three most provocative symptoms out of eight common lower back pain symptoms.  Each patient was asked to indicate on a pain drawing his/her primary source of pain and to describe in writing any position that would provide comfort or relief from the pain.

The diagnosis of SIJ dysfunction was determined by use of manual testing.  The manual dynamic tests were:  Sitting Flexion Test, March/Stork Test, Standing Flexion Test and Supine Long-Sitting Test.  The static bilateral symmetrical test procedures were:  Anterior Superior Iliac Spine (ASIS), Iliac Crest, Posterior Superior Iliac Spine (PSIS), Symphysis Pubis and Sacral Obliquity.  If one or more tests in each category were positive and a generalized region of pain in the SIJ area was present, the patient’s diagnosis was determined to be SIJ dysfunction.  The therapist then noted areas of palpable tenderness around the lumbo-pelvic area.

 

Manual Dynamic Tests

The Supine Long-Sitting Test:   The patient is supine and the examiner’s thumbs are placed under the inferior border of each medial malleolus.  The two medial malleoli are brought together for comparison.  Then the patient sits with knees extended and the relative lengths of the malleoli are reassessed.

A positive test results when observable changes occur in relative leg length between the two positions.

The Standing Flexion Test:    The patient is standing, knees straight, with feet pointed straight ahead.  The examiner’s thumbs are placed on the inferior aspect of the left and right PSIS.  The patient slowly bends forward as far as possible.  A positive test occurs when one PSIS has moved cranially more than the other.

The Sitting Flexion Test:   The patient is sitting on a table.  The examiner’s thumbs are placed on both PSIS’s in accordance with the Standing Flexion Test.  The patient is then asked to forward bend.  If one PSIS becomes superior in relation to the other, a positive test has occurred.  The superior PSIS is considered to be the dysfunctional side.  The Standing Flexion Test is the same design as the Sitting Flexion Test except that the subject is standing.

The March/Stork Test:   The patient is standing in a neutral spine position.  One thumb of the examiner is on the right PSIS, and the other thumb is on the dorsal cranial surface of the sacrum in line with the PSIS.    The patient flexes at the hip on the examination side.  The PSIS will go downward in comparison to the sacrum.  If there is no downward motion of the PSIS, a positive test has occurred.

 

Static Symmetry Tests

PSIS Bilateral Test:   The patient is prone.  The two PSIS’s are found by placing a thumb under each PSIS.  The two heights are compared at a horizontal level.  A positive test results when the height of one PSIS is uneven.

ASIS Bilateral Test:   The two ASIS’s are found by placing a thumb under each ASIS.  The two heights are compared for horizontal height.  A positive test results when the height of one ASIS is uneven.

The Iliac Crest Test:   The patient is prone.  The iliac crests are found by use of the lateral aspect of the index finger slightly palpating the tip of the iliac crest.  If levels of the index fingers are not even, a positive test has occurred.

The Pubis Symphysis Test:   The patient is supine.  Both thumbs are placed on the anterior surface of the pubis.  If the pubic surfaces are not at equal heights, a positive test has occurred.

The Sacral Obliquity Test:   The patient is prone.  Different levels of the dorsal sacral surface are observed by palpation.  The examiner’s thumbs are placed slightly apart, palpating the dorsal surfaces of each fused segment of the sacrum.  If one thumb is more posterior than the other, a positive test has occurred.

 

Lippitt AB.  Recurrent Subluxation of the sacroiliac joint:  Diagnosis and Treatment.  Bulleting Hospital for Joint Diseases, Vol. 54, No. 2 (1995)  pp. 94-102.

Lippitt AB.  The Facet Joint and Its Role in Spine Pain Management With Facet Joint Injections.  Spine, Vol. 9,

No. 7(1984) pp. 746-750.

Magee JD.  Orthopedic Physical Assessment 3^rd Edition, Philadelphia, PA, W.B. Saunders Company (1997)

pp. 428, 460-505.

McKenzie RA.  The Lumbar Spine Mechanical Diagnosis and Therapy, Walkanae Wellington, New Zealand, Spinal Publications (1981)  pp. 1-3.

Retzlaff EW, Berry AH, Haight AS, et al. The Piriformis Syndrome. J AM Osteopath Assoc. 73:799-807 (1974)

Salvatti E.  The Levator Ani Syndrome and Its Variants.  Gastroenterol Clin North Am. 16:71-78 (1987)

Schwarzer A, April C, Bogduk N.  The sacroiliac Joint in Chronic Low Back Pain. Spine 20:31-37 (1995).

Sims V, Avillar MD, Keating JG, Stinchcomb P, Herrberg J.  The Effectiveness of a Seven-Week Sacroiliac Joint Mobilization and Stabilization Program on a Low Back Population.

Stanhope WD and Ontesti ST.  The Sacroiliac Joint – An Overlooked Cause of Low Back Pain.  The Pain Clinic (October 1999)  pp. 13-17.

Thiele GH.  Coccydynia and Pain In the Superior Gluteal Region And Down The Back Of The Thigh: Causation By Tonic Spasm Of The Levator Ani, Coccygeus, And Piriformis Muscles And Relief By Massage Of These Muscles.

(JAMA 109:1271-1275 (1937).

Thiele GH.  Coccydynia:  Case And Treatment.  Dis Colon Rectum.  6:422-426 (1963).

Wallacek K.  Female Pelvic Floor Dysfunctions, And Behavioral Approaches To Treatment.  Clin Sports Med 13:2 (1994) pp. 459-481.