The Validity and Reliability of Provocation Tests in the Diagnosis of Sacroiliac Joint Dysfunction

Abstract

Background: Although sacroiliac joint dysfunction (SIJD) is generally regarded as a source of lumbar pain, its anatomical position and the absence of a diagnostic ‘gold standard’ lead to difficulties at examination and differential diagnosis. However, since sacroiliac (SI) joint blocks only provide information about pathologies of joint origin and since SIJD developing secondary to pathologies in structures around the joint can be missed. Provocation and palpation tests also need to be used in diagnosis. Objectives: The purpose of this study was to examine the reliability of clinical examination and provocation tests used in the diagnosis of SIJD. Study Design: Retrospective analysis of prospectively collected data. Setting: Outpatient physical medicine and rehabilitation clinic. Methods: One hundred and seventeen patients presenting with lumbar and/or leg pain and diagnosed with SIJD through clinical evaluation were included in the study. Range of lumbar joint movement, pain location and specific tests used in the diagnosis of SIJD were evaluated. Positivity in 3 out of 6 provocation tests was adopted as the criterion. Results: 75.2% of patients were female and 24.8% were male. Mean age was 46.41 ± 10.45 years. A higher level of females was determined in ender distribution. SIJD was determined on the right in 52.6% of patients and on the left in 47.4%. When SI joint provocation tests were analyzed individually, the highest positivity, in 91.4% patients diagnosed with SIJD, was in the FABER test. The lowest positivity, in 56.4% of patients, was determined in the Ganslen test. The same patients were assessed by the same clinician at 2 different times. In these data, the simple consistence, kappa and PABAK coefficient values of all tests were close to 1 and indicating good agreement. The thigh thrust (POSH) and sacral thrust tests exhibited very good agreement with a kappa coefficient of 0.90 and a PABAK coefficient of 0.92, while the FABER test exhibited good agreement with a kappa coefficient of 0.78 and a PABAK coefficient of 0.92. Limitation: Agreement between different observers was not evaluated, and also no comparison was performed with SI joint injection, regarded as a widely used diagnostic technique. Conclusion: The anatomical position of the SI joint and the lack of a diagnostic ‘gold standard’ make the examination and diagnosis of SIJD difficult. Most SI joint clinical tests have limited reliability and validity on their own, while a multitest regimen consisting of SI joint pain provocation tests is a reliable method, and these tests can be used instead of unnecessary invasive diagnostic SI joint procedures. Key words: Dysfunction, lumbar, sacroiliac joint, provocation test, sacroiliac joint pain, pain pattern

Radiofrequency denervation of the lumbar facet joints: guidelines for the RADICAL randomised controlled trial

“…The group agreed that assessment could be based on a provocation test or clinical suspicion due to the limited reliability and validity of provocation tests. 23…”

“…The group agreed that assessment could be based on a provocation test or clinical suspicion due to the limited reliability and validity of provocation tests. 23 Two of the NLBRPP criteria for selecting patients were considered as optional or containing an optional component for the RADICAL trial. Experiencing 'increased back pain on one or more of the following: extension (more than flexion), rotation, extension/side flexion or extension/rotation' was considered optional because evidence suggests a lack of correlation between these measures and pain arising from the facet joints.…”

<p>A Review and Algorithm in the Diagnosis and Treatment of Sacroiliac Joint Pain</p>

“… 18 Pain is often with movement, can radiate into the ipsilateral groin and into the buttock. 19 The differential of evaluation of low back can be narrowed by the performance of a physical exam and performance of provocative maneuvers for the diagnosis of sacroiliac joint pain.…”

“…Telli et al looked at the validity and reliability of provocation tests in the diagnosis of sacroiliac joint dysfunction in 156 patients, investigating the distraction test, compression test, Gaenslen test, thigh thrust test, sacral thrust test, and Faber test. Diagnosis was made with three or more positive provocation tests, 19 with the highest sensitivity being Faber (91.4%) and lowest probability was Gaenslen test.…”

Evaluation and Management of Sacroiliac Dysfunction Utilizing an Evidence-Based Algorithmic Approach: A Case Study

“…Managing patients with SIJ dysfunction is difficult due to the multifactorial causes of pain and poor diagnostic clarity during workup. There is low correlation between patient history and diagnosis, limited diagnostic accuracy with imaging [ 2 ], and poor validity and reliability of single provocation or special tests during physical exam [ 7 ]. Diagnostic clarity may be achieved through an SIJ double anesthetic block; however, this requires consultation with an interventional specialist.…”