Approximation (Transverse Posterior Stress) Test.5,38

The patient is in the side lying position, and the examiner’s hands are placed over the upper part of the iliac crest, pressing toward the floor (Figure 10-25). The movement causes forward pressure on the sacrum. An increased feeling of pressure in the sacroiliac joints indicates a possible sacroiliac lesion and/or a sprain of the posterior sacroiliac ligaments.

The patient lies in the supine position. The examiner slightly flexes, abducts, and laterally rotates the patient’s thigh at approximately 45° from the midline. The examiner then applies a graded force through the long axis of the femur, which causes an anterior-to-posterior shear stress to the sacroiliac joint on the same side (Figure 10-26).⁴²

 Gapping (Transverse Anterior Stress or Distraction Provocation) Test.5,38

The patient lies supine while the examiner applies crossed-arm pressure to the ASIS (Figure 10-27, A) (some examiners prefer not to cross arms, Figure 10-27, B). The examiner pushes down and out with the arms. The test is positive only if unilateral gluteal or posterior leg pain is produced, indicating a sprain of the anterior sacroiliac ligaments. Care must be taken when performing this test. The examiner’s hands pushing against the ASIS can elicit pain, because the soft tissue is being compressed between the examiner’s hands and the patient’s pelvis.

 Ipsilateral Prone Kinetic Test.5,8

This test is designed to assess the ability of the ilium to flex and to rotate laterally or posteriorly. The patient lies prone while the examiner places one thumb on the PSIS and the other thumb parallel to it on the sacrum. The patient is then asked to actively extend the leg on the same side (Figure 10-28). Normally, the PSIS should move superiorly and laterally. If it does not, it indicates hypomobility with a posterior rotated ilium, or outflare.

 Passive Extension and Medial Rotation of Ilium on Sacrum.5,8

The patient is in side lying position on the side that is not being tested. The examiner places one hand over the ASIS area of the anterior ilium. The other hand is placed over the PSIS in such a way that the fingers of the hand palpate the posterior ilium and sacrum. The examiner then pulls the ilium forward with the hand over the ASIS and pushes the posterior ilium forward with the other hand while feeling the relative movement of the ilium on the sacrum (Figure 10-29). The unaffected side is then tested for comparison. If the affected side moves less, it indicates hypomobility and a posterior rotated ilium, or outflare.

The patient is positioned as for the previously mentioned test. In this case, the examiner pushes the anterior ilium backward with the anterior hand, and the posterior hand and arm pull the ilium posteriorly while palpating the relative movement (Figure 10-30). The unaffected side is then tested for comparison. If the affected side moves less, it is a sign of hypomobility and an anterior rotated ilium, or inflare.

If both this test and the previously mentioned one are positive, it means an upslip has occurred to the ilium relative to the sacrum.

The patient lies supine. The examiner flexes the hip and knee to 90° and then laterally rotates the hip. This movement, provided the hip is normal, stresses the sacroiliac joint on the test side.10

The posterior sacroiliac ligaments may be stressed with the patient in the prone position (Figure 10-27, C). To perform the test, the patient’s hips must have full ROM and be pathology free. The patient lies prone, and the examiner stabilizes the pelvis with his or her chest. The patient’s knee is flexed to 90° or greater, and the hip is medially rotated as far as possible. While pushing the hip into the very end of medial rotation, the examiner palpates the sacroiliac joint on the same side. The test is repeated on the other side, with the examiner comparing the degree of opening and the quality of the movement at each sacroiliac joint as well as stressing the posterior sacroiliac ligaments.

 Sacral Apex Pressure (Prone Springing or Sacral Thrust) Test.38

The patient lies in a prone position on a firm surface while the examiner places the base of his or her hand at the apex of the patient’s sacrum (Figure 10-31). Pressure is then applied to the apex of the sacrum, causing a shear of the sacrum on the ilium. The test may indicate a sacroiliac joint problem if pain is produced over the joint. The test causes a rotational shift of the sacroiliac joints.

This test is also called the sacrotuberous ligament stress test. The patient is in a supine position (Figure 10-32). The examiner flexes the patient’s knee and hip fully and then adducts the hip. To perform the test properly, both the hip and knee must demonstrate no pathology and have full range of motion (ROM). The sacroiliac joint is “rocked” by flexion and adduction of the patient’s hip. To do the test properly, the knee is moved toward the patient’s opposite shoulder. Some authors^5,42 believe that the hip should be medially rotated as it is flexed and adducted to increase the stress on the sacroiliac joint. Simultaneously, the sacrotuberous ligament may be palpated (see Figure 10-2 for location) for tenderness. Pain in the sacroiliac joints indicates a positive test. Care must be taken, because the test places a great deal of stress on the hip and sacroiliac joints. If a longitudinal force is applied through the hip in a slow, steady manner (for 15 to 20 seconds) in an oblique and lateral direction, further stress is applied to the sacrotuberous ligament.⁵ While performing the test, the examiner may palpate the sacroiliac joint on the test side to feel for the slight amount of movement that normally is present.

With the patient in the supine position, the examiner places both hands on the patient’s ASISs and iliac crests and pushes down and in at a 45° angle (Figure 10-33). This movement tests the posterior sacroiliac ligaments. A positive test is indicated by pain.

 Superoinferior Symphysis Pubis Stress Test.5,8

The patient lies supine. The examiner places the heel of one hand over the superior pubic ramus of one pubic bone and the heel of the other hand over the inferior pubic ramus of the other pubic bone. The examiner then squeezes the hands together, applying a shearing force to the symphysis pubis (Figure 10-34). Production of pain in the symphysis pubis is considered a positive test.

 Thigh Thrust Test (Also Called Oostagard, 4P, Sacrotuberous Stress, or POSH [Posterior Shear] Test).38

The patient lies supine while the examiner passively flexes the hip on the test side to 90°. Using one hand to palpate the sacroiliac joint, the examiner thrusts down through the knee and hip on the text side (Figure 10-35). Pain in the sacroiliac joint on thrusting is a positive test.

 Torsion Stress Test.5

The patient lies prone. The examiner palpates the spinous process of L5 with one thumb holding it stable. The examiner’s other hand is placed around the anterior ilium on the opposite side and lifts the contralateral ilium up (Figure 10-36). This rotational movement stresses the lumbosacral junction, the iliolumbar ligament, the anterior sacroiliac ligament, and the sacroiliac joint.

Normally, this is used to test for a tight rectus femoris, an upper lumbar joint lesion, an upper spine nerve root lesion, or a hypomobile sacroiliac joint. The patient lies prone, and the examiner flexes the knee so that the heel is brought to the buttocks. If pain is felt in the front of the thigh before full range is reached, the problem is in the rectus femoris muscle. If the pain is in the lumbar spine, the problem is in the lumbar spine, usually the L3 nerve root, especially if these are radicular symptoms. If the problem is a hypomobile sacroiliac joint, the ipsilateral pelvic rim (ASIS) rotates forward, usually before the knee reaches 90° flexion.42,46

Although the Lasègue sign is primarily considered a test of the neurological tissue around the lumbar spine, this test also places a stress on the sacroiliac joints. With the patient in the supine position (Figure 10-37), the examiner passively flexes the patient’s hip with the knee extended. Pain occurring after 70° is usually indicative of joint pain. However, in hypermobile persons, joint pain is often not experienced until after 120° of hip flexion. Therefore, it is more important to watch for the production of the patient’s symptoms than for the actual ROM. In addition, the ROM obtained should be compared with the unaffected side. If the examiner then does a passive bilateral straight leg raising (SLR) test in a similar fashion, pain occurring before 70° is usually indicative of sacroiliac joint problems. DonTigny⁴⁷ has reported that the straight leg raise can be affected by sacroiliac problems. If, when doing SLR, the pain in the sacroiliac joint is unaltered or decreases, the examiner may suspect an anterior torsion. If the pain increases in the sacroiliac joint, a posterior torsion is possible. If pain increases on the opposite side, an anterior torsion on the opposite side should be suspected.

Lee⁵ advocated several modifications to the straight leg test (Figure 10-38, A) if sacroiliac joint problems are suspected. These tests are called active SLR tests and were originally designed to test for postpartum pelvic problems.^48–50 In the first modification, Lee recommends that the test be done actively by the patient in supine (supine active straight leg raise test ).^12,48–50 As the patient actively lifts the leg, the examiner asks whether the patient notes any “effort differences” between the two sides. The examiner then stabilizes and compresses the pelvis while the patient actively does the straight leg raise providing form closure of the joints by squeezing the innominate bones together anteriorly (Figure 10-38, B). If the pain decreases or the SLR is easier to do with form closure (with no increased neurological signs), the test is considered positive for possible sacroiliac joint problems. At the same time, the examiner can check the contraction of the pelvic floor/transverse abdominus/multifidus force couple by palpating medial to the ASIS bilaterally. If the force couple functions properly, tension is felt symmetrically and the abdomen moves inward. If superficial tension is felt, it means the internal obliques are contracting, and there is a force-couple imbalance.¹² Multifidus may be palpated close to the spinous process, and it should contract when the pelvic floor contracts. Another modification tests force closure at the sacroiliac joints.⁵ The patient is asked to flex and rotate the trunk toward the side that the SLR is actively being performed. The trunk motion is resisted by the examiner (Figure 10-38, C). The two sides are compared for any difference. Force closure tests the ability of the muscles to stabilize the sacroiliac joints during movement.

Lee⁵ also advocates doing active hip extension (active prone hip extension test) with the leg straight under three conditions (prone active straight leg raise test ). The first condition is hip extension (Figure 10-39, A). The second condition includes the same movement as the first with the examiner applying manual compression to the innominate bones (form closure) (Figure 10-39, B). The third condition has the examiner resisting extension of the contralateral medially rotated arm (force closure) as the patient extends the straight leg (Figure 10-39, C). If function improves when force closure stabilization is used, exercise will probably benefit the patient.

A more detailed description of the SLR test is given in Chapter 9.

The patient is asked to stand on one leg (Figure 10-40). When the patient is standing on one leg, the weight of the trunk causes the sacrum to shift forward and distally (caudally) with forward rotation. The ilium moves in the opposite direction. On the non–weight-bearing side, the opposite occurs, but the stress is greatest on the stance side.¹⁰ Pain in the symphysis pubis or sacroiliac joint indicates a positive test for lesions in whichever structure is painful. The stress may be increased by having the patient hop on one leg. This position is also used to take a stress x-ray of the symphysis pubis.

The patient lies on the side with the upper leg (test leg) hyperextended at the hip (Figure 10-41, A). The patient holds the lower leg flexed against the chest. The examiner stabilizes the pelvis while extending the hip of the uppermost leg. Pain indicates a positive test. The pain may be caused by an ipsilateral sacroiliac joint lesion, hip pathology, or an L4 nerve root lesion.

Gaenslen’s test is sometimes done with the patient supine (Figure 10-41, B), but this position may limit the amount of hyperextension available. The patient is positioned so that the test hip extends beyond the edge of the table. The patient draws both legs up onto the chest and then slowly lowers the test leg into extension. The other leg is tested in a similar fashion for comparison. Pain in the sacroiliac joints is indicative of a positive test.

 Gillet’s (Sacral Fixation) Test.20

This test is also called the ipsilateral posterior rotation test. While the patient stands, the sitting examiner palpates the PSISs with one thumb and the other thumb parallel with the first thumb on the sacrum. The patient is then asked to stand on one leg while pulling the opposite knee up toward the chest. This causes the innominate bone on the same side to rotate posteriorly. The test is repeated with the other leg palpating the other PSIS. If the sacroiliac joint on the side on which the knee is flexed (i.e., the ipsilateral side) moves minimally or up, the joint is said to be hypomobile, or “blocked,” indicating a positive test.³⁰ On the normal side, the test PSIS moves down or inferiorly (Figure 10-42). This test is similar to the test performed during hip flexion in active movement; the only difference is the points of palpation during the movement.

Jackson⁴ has suggested a modification to the test. After completing the Gillet’s test, he suggests that the examiner palpate the same PSIS and sacrum and ask the patient to do a repeat of the Gillet test using the other leg, which causes the opposite innominate bone to rotate posteriorly. As the patient flexes the hip and knee, the lumbar spine begins to flex, causing the sacrum to move inferiorly and resulting in the test innominate (side opposite to the leg being flexed) to rotate anteriorly.

The patient lies supine. The examiner places one hand under the lumbar spine so that each finger is in an interspinous space (i.e., L5–S1, L4–L5, L3–L4, and L2–L3 interspaces). The examiner uses the other hand to perform SLR. If pain is elicited before movement occurs at the interspaces, the problem is in the sacroiliac joint. Pain during interspace movement indicates a lumbar spine dysfunction. As with the SLR test, pain may be referred along the course of the sciatic nerve if there is neurological (e.g., nerve root) involvement.46

 Ipsilateral Anterior Rotation Test.5

The patient stands with weight equally distributed on both feet. The examiner sits behind the patient and palpates one PSIS with one thumb and the sacrum on a parallel line with the other thumb. The patient is asked to extend the ipsilateral leg. Normally, the PSIS should move superiorly and laterally (Figure 10-43). The other side is tested for comparison. This test determines the ability of the innominate on the test side to rotate anteriorly while the sacrum rotates to the opposite side.⁵

The patient lies supine (Figure 10-44). To test the left sacroiliac joint, the examiner flexes, abducts, and laterally rotates the patient’s left hip, applying an overpressure at the end of the ROM. The examiner must stabilize the pelvis on the opposite side by holding the opposite ASIS down. Pain in the left sacroiliac joint constitutes a positive test. The other side is tested for comparison. This test should be performed with caution for patients with hip pathology, because hip pain may ensue.

 Mazion’s Pelvic Maneuver (Standing Lunge Test).51

The patient stands in a straddle position with the limb on the unaffected side forward so that the feet are 0.5 to 1 meter (2 to 3 feet) apart. The patient bends forward, trying to touch the floor, until the heel of the back leg lifts off the floor. If pain is produced in the lower trunk on the affected side, it is considered a positive test for unilateral forward displacement of the ilium relative to the sacrum.

See Chapter 11.

The patient is asked to sit on a hard, flat surface (Figure 10-45). This position keeps the muscles (e.g., hamstrings) from affecting the pelvic flexion symmetry and increases the stability of the ilia. In effect, it is a test of the sacrum on the ilia. The examiner palpates the PSISs and compares their heights. If one PSIS, usually the painful one, is lower than the other, the patient is asked to forward flex while remaining seated. If the lower PSIS becomes the higher one on forward flexion, the test is positive; it is that side that is affected. Because the affected joint does not move properly and is hypomobile, it goes from a low to a high position. This is believed to indicate an abnormality in the torsion movement at the sacroiliac joint.

The patient lies supine with the legs straight. The examiner ensures that the medial malleoli are level. The patient is asked to sit up, and the examiner observes whether one leg moves up (proximally) farther than the other (Figures 10-46 and 10-47). If so, it is believed that there is a functional leg length difference resulting from a pelvic dysfunction caused by pelvic torsion or rotation.^42,52,53 It may also be caused by spasm of the lumbar muscles in the presence of lumbar pathology.

The patient lies prone. The examiner flexes the patient’s knee to 90° and extends the hip (Figure 10-48). Pain localized to the sacroiliac joint indicates pathology in the anterior sacroiliac ligaments. Lumbar pain indicates lumbar involvement.⁴⁶ Anterior thigh paresthesia may indicate a femoral nerve stretch.

 Functional Limb Length Test.54

The patient stands relaxed while the examiner palpates the ASISs and PSISs, noting any asymmetry. The patient is then placed in the “correct” stance (subtalar joints neutral, knees fully extended, and toes facing straight ahead), and the ASISs and PSISs are palpated with the examiner noting whether the asymmetry has been corrected. If the asymmetry has been corrected by “correct” positioning of the limb, the leg is structurally normal (i.e., the bones have proper length), but abnormal joint mechanics (functional deficit) are producing a functional leg length difference. Therefore, if the asymmetry is corrected by proper positioning, the test is positive for a functional leg length difference.

The leg length test, described in detail in Chapter 11, should always be performed if the examiner suspects a sacroiliac joint lesion. Nutation (backward rotation) of the ilium on the sacrum results in a decrease in leg length—as does counternutation (anterior rotation) on the opposite side. If the iliac bone on one side is lower, the leg on that side is usually longer.⁴⁷ True leg length is measured by placing the patient in a supine position with the ASISs level and the patient’s lower limbs perpendicular to the line joining the ASISs (Figure 10-49). Using a flexible tape measure, the examiner obtains the distance from the ASIS to the medial or lateral malleolus on the same side. The measurement is repeated on the other side, and the results are compared. A difference of 1 to 1.3 cm (0.5 to 1 inch) is considered normal. It should be remembered, however, that leg length differences within this range may also be pathological if symptoms result.⁵⁵

 Functional Hamstring Length.5

The patient sits on the examining table with the knees flexed to 90°, no weight on feet, and spine in neutral. The examiner sits behind the patient and palpates the PSIS with one thumb while the other thumb rests parallel on the sacrum. The patient is asked to actively extend the knee (Figure 10-50). Normally, full knee extension is possible without posterior rotation of the pelvis or flexion of the lumbar spine. Tight hamstrings would cause the pelvis to rotate posteriorly and/or the spine to flex.

See Chapters 11 and 12.

With the patient supine, the examiner performs a passive unilateral SLR test as done previously (Figure 10-51). If restriction or pain is found on one side, the examiner flexes the patient’s knee while holding the patient’s thigh in the same position. Once the knee is flexed, the examiner tries to flex the hip further. If the problem is in the lumbar spine or hamstrings, hip flexion increases. This finding indicates a negative sign of the buttock test. If hip flexion does not increase when the knee is flexed, it is a positive sign of the buttock test and indicates pathology in the buttock, such as a bursitis, tumor, or abscess. The patient with this pathology would also exhibit a noncapsular pattern of the hip.

 Thoracolumbar Fascia Length.5

The patient sits on the examining table with the knees bent to 90° and a neutral spine. The examiner stands behind the patient. The patient is asked to rotate left and right fully and the examiner notes the ROM available (Figure 10-52, A). The patient is then asked to forward flex the arms to 90° and laterally rotate and adduct the arms so the little fingers touch each other and palms face up (Figure 10-52, B). Holding this arm position, the patient is again asked to rotate left and right as far as possible. The motion will be restricted in the second set of rotations if the thoracolumbar fascia or latissimus dorsi are tight.

The patient is asked to stand or balance first on one leg and then on the other (Figure 10-53). While the patient is balancing on one leg, the examiner watches the movement of the pelvis. If the pelvis on the side of the non-stance leg rises, the test is considered negative, because the gluteus medius muscle on the opposite (stance) side lifts it up as it normally does in one-legged stance. If the pelvis on the side of the non-stance leg falls, the test is considered positive and is an indication of weakness or instability of the hip abductor muscles, primarily the gluteus medius on the stance side. Therefore, although the examiner is watching what happens on the non-stance side, it is the stance side that is being tested.

Meralgia Paresthetica.56

This condition is the result of pressure or entrapment of the lateral femoral cutaneous nerve near the ASIS, because the nerve passes under the inguinal ligament. It may result from trauma such as that caused by a seat belt in a car accident, during delivery (in stirrups), by tight clothing, or as a complication of surgery (e.g., hernia). This nerve is sensory only, so the patient experiences sensory alteration and/or burning pain on the lateral aspect of the thigh (Figure 10-56).

Ilioinguinal Nerve.57

This nerve, which lies within the transverse abdominus muscle, may be compressed by spasm of the muscle (Figure 10-57). The nerve is sensory only, and the sensory alteration and/or pain occurs in the superior aspect of the anterior thigh (in the L1 dermatome area), as well as in the scrotum or labia. There have been reports in the literature^58–61 that this nerve may be entrapped with injury to the external oblique muscle aponeurosis (hockey player’s syndrome). The patient feels pain especially on ipsilateral hip extension and contralateral torso rotation. The pain may radiate to the groin, scrotum, hip, and back.

Superoinferior Translation of Symphysis Pubis.5

The patient lies supine. The examiner places the heel of one hand on the superior aspect of the superior ramus of one pubic bone and the heel of the other hand on the inferior aspect of the superior ramus of the opposite pelvic bone. A slow steady inferior force is applied with the uppermost hand while a superior force is applied with the lower hand (Figure 10-64). The examiner is testing the end feel and looking for the production of symptoms.

The examiner returns to the ASIS and gently palpates the length of the inguinal ligament, feeling for any tenderness or swelling of the lymph nodes or possible inguinal hernia. At the distal end of the inguinal ligament, the examiner comes to the pubic tubercles and symphysis pubis,64 which should be palpated for tenderness or signs of pathology.

The examiner then places the thumbs over the pubic tubercles and moves the fingers laterally until the bony greater trochanter of the femur is felt. The trochanters are usually level. The trochanteric bursa lies over the greater trochanter and is palpable only if it is swollen.

Returning to the ASIS, the examiner can move on to palpate the femoral triangle, which has as its boundaries the inguinal ligament superiorly, the adductor longus muscle medially, and the sartorius muscle laterally. It is in the superior aspect of the triangle that the examiner palpates for swollen lymph nodes. The femoral pulse can be palpated deeper in the triangle. Although almost impossible to palpate, the femoral nerve lies lateral to the artery, whereas the femoral vein lies medial to it. The psoas bursa may also be palpated within the femoral triangle, but only if it is swollen. Before moving on to the posterior structures, the examiner should determine whether the adjacent musculature—the abductor, flexor, and adductor muscles—shows any indication of pathology (e.g., muscle spasm, pain).

If the examiner then moves slightly medially and distal to the PSIS, the fingers rest adjacent to the sacroiliac joints. To palpate these joints, the patient’s knee is flexed to 90° or greater, and the hip is passively medially rotated while the examiner palpates the sacroiliac joint on the same side (Figure 10-66). This procedure is identical to the prone gapping test previously described in the “Passive Movements” section. The procedure is repeated on the other side, and the two results are compared.

The examiner then returns to the S2 spinous process or tubercle. Carefully palpating farther distally (just before the coccyx), the examiner may be able to palpate the sacral hiatus lying in the midline. If the fingers are moved slightly laterally, the sacral cornua, which constitute the distal aspect of the sacrum, may be palpated (Figure 10-67).

To palpate the coccyx properly, the examiner performs a rectal examination (Figure 10-68). A rubber glove is put on, and the index finger is lubricated. The index finger is then carefully pushed into the rectum as the patient relaxes the sphincter muscles. The index finger then palpates the anterior surface of the coccyx while the thumb of the same hand palpates its posterior aspect. While holding the coccyx between the finger and thumb, the examiner is able to move it back and forth, rocking it at the sacrococcygeal joint. Normally, this action should not cause pain.

The examiner then returns to the PSIS. Moving straight down or distally from the PSIS, the fingers follow the path of the sacrotuberous ligament, which should be palpated for tenderness. Slightly more than halfway between the PSIS and ischial tuberosity and slightly medially, the fingers pass over the sacrospinous ligament, which is deep to the sacrotuberous ligament. Tenderness in this area may indicate pathology of this ligament.