♦ Physical Examination of Sacroiliac Joint:
» Subjective Examination:
- Adopt the general subjective examination approach stressing following key points for SI joint dysfunction:
- History of traumatic incidents like
- Fall on the buttock
- An unexpected heel-strike
- A golf swing
- Abnormal stresses occurring in activities
- Chronic pain after giving birth or starting oral contraceptives
- Past History of other conditions like
- Ankylosing Spondylitis
- Reiter's Disease
- Rheumatoid Arthritis
- Malignant deposits or Paget's Disease (Paget's disease is characteristically aggravated by exercise and is more severe during sleep).
» Pain History:
- Unilateral pain, most often local to the joint itself (PSIS, ASIS, posterior iliac crest), but possibly referring down the leg (usually posterolaterally and not beow the knee) because of innervation from the L2 through S2 segments.
- Sometimes may refer into hip, groin, or abdomen.
- Absence of lumbar articular signs or symptoms.
- Aggravated by walking, rolling over in bed, and climbing stairs, especially when leading with the involved side.
- Increased pain with prolonged postures or with standing or sitting on the affected side (twisted sitting posture).
- Morning stiffness that eases after a short period of weight bearing.
- Follow the routine observation keeping in mind following points:
- Bipedal striding requires optimal lumbar-pelvic-hip function.
- Leg length discrepancy
- Accompanying excessive or decreased lordosis
- Painful SI joint may cause reflexive inhibition of the gluteus medius, leading to a Trendelenburg gait or lurch .
- Patient might sidebend the trunk away from the painful side or walk with difficulty.
- Postural instability does not always indicate pelvic girdle dysfunction but pelvic girdle dysfunction is often reflected through postural asymmetry.
- Observe patient's posture
- Sitting (on a stool or bench without back support)
- Long Sitting
- Carefully observe distribution of body weight through the lower quadrant.
- In weight bearing, note whether the patient stands with equal weight on both feet or has a lateral pelvic tilt - suggesting an apparent or real leg length discrepancy.
- Patient tend to bear weight on the unaffected side in standing & sitting and to step up with the unaffected side.
- Posture of the feet (pronation/supination) and Knees (hyperextension, varus, valgus). Variations in these joints can be the result of compensation for a longstanding leg length discrepancy.
- In anterior dysfunction of innominate, lowerlimb might be medially rotated.
- Spasm of piriformis muscle can cause lateral rotation on the affected side.
- Look for muscle, connective tissue asymmetry or increased muscle activity which might correlate with abnormal structural deviations.
- In standing position, compare the levels of ASIS, PSIS and the iliac crest.
- If the ASIS is higher on one side with lower PSIS - Anterior torsion of sacrum (nutation) on that side which is common with spinal scoliosis, an altered functional leg length or both.
- Palpate the summit of the greater trochanter for levelness - apparent or structure leg length discrepancy.
- In sitting (erect on a level surface), repeat palpation of the bony landmarks of the innominate. Determine whether lateral pelvic till is still present or whether the previous lateral tilt in standing is now eradicated.
- In hyperflexion (sitting, feet supported, knees at a right angle and apart, sufficient to allowthe shoulders to come between them & lumbar spine to be fully flexed), [2,3]
- Determine position of sacrum by comparing
- Posteroanterior relation of the sacral base
- Depth of the two sacral sulci
- The inferior angles
- Palpate sacral depth (dorsal ventral distance) using thumbs between the PSIS and the base of sacrum, medially from the caudal aspect of the PSIS bilaterally.
- If one sacral base is more anterior than the other, sacral sulcus is said to be deep on that side.
- Inferior lateral angle is the transverse process of S5 - place one finger on the sacral hiatus & index and middle fingers of other hand on either side at the same level about 2 cm away.
- Anterior right sacral base or deep anterior sacral sulcus together with a left inferior lateral angle - Left Rotated Sacrum [3,4].
- Also evaluate in neutral (prone) and finally in hyperextension.
- Patient in supine and crook position, ask him to lift and drop the buttocks or do it for the patient. Bring knees to the chest & slowly the legs down with the knees extended.
- Check the iliac crest for asymmetry - Palpate the highest point of the iliac crest with radial border of index finger.
- Ilium is inflared (one ilium ASIS is closer to the midline than the opposite ASIS) or outflared (one ilium is further from the midline than the opposite ASIS).
- Pubic Symphysis - Place thumbs on the superior aspect of each pubic bone and compare the height.
- In prone, determine the following:
- Palpate coccyx
- Anteroposterior Angulation (any deviation to one side)
- Tenderness around its tip
- Thickening or hypertrophy of soft tissue inserting into it
- Palpate ischial tuberosities - using thumbs over the caudal aspect of the ischial tuberosity bilaterally
- One tuberosity higher - may indicate upslip of the ilium on the sacrum on that side .
- Position of sacrum
- One sacral sulcus deeper than the other - possibility of sacral torsion .
- In press-up or backward-bending position (prone on elbows with patient's chin resting in the hands and the lumbar spine in hyperextension)
- Sacral sulci - relative depth from neutral prone position
- Side that is blocked will remain shallow & the side that is free to move will go deeper [5,6].
- Inferior lateral angles
- If the angle opposite the deep sacral sulcus becomes more posterior - Forward Sacral Torsion.
- If the angle is more inferior on the same side as the deep sacral sulcus - Unilateral Sacral Flexion .
- Palpate all the muscles and ligaments for tenderness and imbalance.
» General Examination of Back Video:
» Examination of Back
» Special Tests:1) Belt Test (Supported Forward Bend Test):
- Forward bending requires normal function in the sacroiliac joint and the lumbosacral junction as well as mobility in the individual segments of the lumbar spine.
- Pain in unguided motion suggests a sacroiliac syndrome; this pain will improve or disappear in guided motion with the pelvis immobilized.
- Changes in the lumbar spine will produce pain in forward bending with or without support.2) Standing Flexion Test:
- If nutation does not occur in the sacroiliac joint on one side, the PSIS on that side will come to rest farther superior with respect to the sacrum than the spine on the contralateral side.
- Where nutation fails to occur or this relative superior advancement is observed, this is usually a sign of a blockade in the ipsilateral sacroiliac joint. Bilateral superior advancement can be simulated by bilateral shortening of the hamstrings.
- When evaluating this superior advancement phenomenon, the examiner must consider or exclude possible asymmetry of the pelvis and hips. Pelvic obliquity due to a difference in leg length should be compensated for by placing shims under the shorter leg.
- The standing flexion test can also be performed with the patient supine. The supine patient is asked to sit up (the patient may use his or her arms for support on the edge of the examining table).
- The examiner places both thumbs on the tips of the medial malleoli. As the patient sits up, the right malleolus will be seen to “advance” asymmetrically compared with its position in the supine patient. This is a sign of impaired mobility in the right sacroiliac joints.
3) Piedallu's Sign (Seated Flexion Test):
4) Pelvic Compression Test:
5) Pelvic Distraction Test:
6) Lateral (Ilium) Compression Test:
7) Patrick's Test (FABER-Flexion Abduction External Rotation):
- Apart from assessing the tension in the adductors, also consider whether the shortening of the adductors is attributable to hip pain (a soft endpoint) or sacroiliac motion restriction (differential diagnosis).
- A simple restriction of movement in the hip (hard endpoint) or a intervertebral dysfunction in the lumbar spine can also produce a positive faber sign.
8) Gaenslen's Test:
9) Yeoman's Test:
10) Ligament's Test:
- Patient is in prone position for all the three test.
- To evaluate the iliolumbar ligament, the patient’s knee and hip are flexed and the examiner then adducts the leg to the contralateral hip. While executing this maneuver, the examiner presses on the knee to exert axial pressure on the femur.
- To evaluate the sacrospinous and sacroiliac ligaments, the patient’s knee and hip are maximally flexed and the examiner adducts the leg toward the contralateral shoulder. While executing this maneuver, the examiner presses on the knee to exert axial pressure on the femur.
- To evaluate the sacrotuberal ligament, the patient’s knee and hip are maximally flexed and the examiner moves the leg toward the ipsilateral shoulder.
- Stretching pain occurring within a few seconds suggests functional shortening and excessive stresses on the ligaments, although it can also occur in a hypermobile or motion-restricted sacroiliac joint.
- Pain occurs at following for different ligaments:
- Stretching the iliolumbar ligament causes referred pain to the inguinal region (the differential diagnosis includes a hip disorder).
- Pain caused by stretching the sacrospinous and sacroiliac ligaments is felt within the S1 dermatome from a point posterolateral to the hip as far as the knee.
- Sacrotuberal ligament pain radiates into the posterior aspect of the thigh.
11) Springing Test:
♦ Physical Therapy Management of SI Joint Dysfunction:
» Soft Tissue Manipulation:
- Janda  has indentified the common pattern of muscle imblances that occur in the lower quadrant with hypertonic postural muscles nad muscles showing a tendency toward inhibition and reflex muscle meakness of antagonistic group of muscles.
- Muscle imbalances result in faulty postures, joint malalignment and development of altered inefficient movement patterns resulting in strain and degeneration of joints, myofascial and ligamentous structures.
- This type of syndrome is known as Pelvic Floor Cross Syndrome which results in following musculature imbalance.
Clinical consequences of the lower crossed syndrome include increased thoracolumbar facet and SI joint strain, altered hip mechanics, and overstress of the the lumbosacral junction [12,13,14].
Soft tissue manipulations to consider include
- Myofascial Release Manipulations
- Thoracolumbar fascia
- Lumbar mass
- Postisometric Relaxation and Stretching
- Hip Adductors
- Quadratus Lumborum
- Latissimus Dorsi
- Erector Spinae
- Tensor Fasica Lata
» Joint Mobilization:
- The role of mobilization is limited to passive mobility, but the most important part of treatment deals with active mobility and patient self-treatment or mobilization on an ongoing basis outside the clinical setting.
- Treatment will not bring the expected relief of symptoms unless soft tissue dysfunctions are addressed in addition to the loss of muscle strength and flexibility.
- CLINICAL PREDICTION RULE: 
The presence of more variables of five in the prediction rule increases the likelihood of success with manipulation.
- Duration of symptom < 16 Days
- Fear-Avoidance Beliefs Questionnaire (FABQ) work subscale score < 19
- At least one hip with > 35 degrees of internal rotation ROM
- Hypomobility in the lumbar region
- No Symptoms distal to the knee
- Joint Mobilization Techniques used for SI Joint Dysfunction:
» Mulligan Joint Mobilization with Movement:
- Mulligan refers SIJ dysfunction as osteopathic in origin.
- He describes two positional faults encountered in the SIJ can cause pain.
- One is called posterior innonimate, where the ilium is slightly backwards on its sacral facet and the other is the opposite called the anterior innonimate positioning.
- POSTERIOR INNOMINATE:
- Pain with back extension in standing and/or lying, as well as with spring test.
- Patient Position:
- Prone Lying
- Therapist's Position:
- Stand to the opposite side of the affected SI Joint
If the right SI joint is involved then place the thenar eminence of your right hand on the posterior border of the right ilium and push it laterally (away from you).
This should produce no pain.
Now have the patient do a passive extension in lying (half press-up).
Repeat 10 times and if the procedure is correct the patient would have less pain.
- ANTERIOR INNOMINATE:
- Patient Position:
- Prone Lying
- Therapist's Position:
- Stand to the side of the patient
- Fixate the sacrum with the border of one hand and place the fingers of the other hand under the right ASIS if the right SI Joint is involved.
- Pull up the ilium on the sacrum and hold this position while the patient does 10 half press-ups, provided these are pain free.
These techniques are done in standing if the patient has pain of SI Joint while standing extension.
Same is applicable if patient has SIJ pain in walking as is more common. The patient is made to walk after holding the ilium backwards in the position as mentioned in the above technique.