Diagnóstico Clínico da Dor Sacroilíaca

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<p>Clinical Diagnosis of Sacroiliac Joint Pain</p><p>Mark Laslett, NZRPS, PhD, FNZCP, Dip.MT, Dip.MDT</p><p>Summary: There is a need to establish a standardized clinical exami-</p><p>nation, based on best available evidence, that identifies those patients with</p><p>persistent back and buttock pain whose symptoms arise from the sacroiliac</p><p>joint. This clinical examination is the first step in the selection of patients</p><p>for controlled and guided diagnostic intra-articular block (the reference</p><p>standard). This in turn is the prerequisite for selection of patients for</p><p>minimally invasive therapies such as intra-articular steroid injection or for</p><p>surgical fusion. The use of pain location and results from pain provocation</p><p>tests is described within the context of a clinical reasoning algorithm.</p><p>A cluster of at least 2, preferably 3 provocation tests in the absence of any</p><p>clear diagnosis of a pain source other than the sacroiliac joint, has a</p><p>sensitivity of 91% and specificity of 89%. The clinical examination</p><p>described is reliable, requires no special equipment, and is available from</p><p>trained clinicians in most developed countries.</p><p>Key Words: SIJ pain—clinical diagnosis—diagnostic accuracy—intra-</p><p>articular injection—pregnancy-related pelvic girdle pain.</p><p>(Tech Orthop 2018;00: 000–000)</p><p>T he purpose of this article is to establish the best-evidence</p><p>case for clinical diagnosis of sacroiliac joint (SIJ) pain,</p><p>selecting patients for conservative therapies, minimally invasive</p><p>diagnostic tests, or surgical intervention. Clearly a high stand-</p><p>ard of certainty that the origin of pain is in fact the SIJ is</p><p>needed, if surgical fusion is to be offered as an intervention.</p><p>The innervation of the sacroiliac (SI) joint is complex and</p><p>diverse.1 Stimulation of the SIJ in asymptomatic volunteers</p><p>produces pain.2 Buttock and lower extremity pain can be</p><p>ablated by the introduction of local anesthetic into the joint</p><p>space under image intensifier guidance,3 and pain referral maps</p><p>in symptomatic patients are available.4 These facts provide a</p><p>strong case for the SIJ as a potential and possibly sole source of</p><p>pain in specific patients with buttock and lower extremity</p><p>pain.5–7</p><p>SIJ pain is a quite distinct from and should not be con-</p><p>fused with the hypothetical condition of SIJ dysfunction. SIJ</p><p>pain is simply pain arising from SIJ structures. SIJ dysfunction</p><p>is alleged to be some sort of mechanical aberration of move-</p><p>ment or position of the ilium in relation to the sacrum, detect-</p><p>able only by manual therapy clinicians. This conceptual con-</p><p>struct may be rejected on the basis that the amount of</p><p>movement available is so small, as to be undetectable by pal-</p><p>pation, and seems unrelated to the side of pain.8 Furthermore,</p><p>the palpation tests used are unreliable9 and are not valid pre-</p><p>dictors of intra-articular SIJ blocks.10</p><p>The SIJ may be a cause of presentation for diagnosis and</p><p>treatment in perhaps 13% (95% confidence interval: 9%-26%)</p><p>of patients with persistent low back pain.11 Prevalence will vary</p><p>substantially, dependent on setting, with possibly 50% of</p><p>patients presenting with pregnancy-related pelvic girdle pain,</p><p>having painful SIJs.12 There are 2 known subsets of SIJ pain</p><p>that can be identified using current knowledge and expertise:13</p><p>(1) Intra-articular SIJ pain, which may be diagnosed using</p><p>controlled intra-articular blocks, but not lateral branch</p><p>blocks.</p><p>(2) Extra-articular SI ligamentous pain, which may be</p><p>diagnosed using blockage of the lateral branches of the</p><p>S1-S4 dorsal rami,14 but not intra-articular blocks.</p><p>These interventional methods for diagnosing SI pain are</p><p>not without risk, are not technically feasible at the primary care</p><p>level, and may not be available at all in some places. There is a</p><p>need for a simple screening test procedure that requires no more</p><p>than a history and physical examination. It is acknowledged</p><p>that it is impractical, economically unsustainable, and unethical</p><p>to subject all patients presenting with back pain to interven-</p><p>tional diagnostics.15</p><p>Noninvasive diagnostic tests for intra-articular SIJ pain</p><p>has been studied and refined over the last 4 decades. In 1994,</p><p>the International Association for the Study of Pain (IASP)16</p><p>recommended 3 diagnostic criteria:</p><p>(1) Pain is present in the region of the SIJ.</p><p>(2) Stressing the SIJ by clinical tests that are selective for the</p><p>joint reproduces the patient’s pain, or</p><p>(3) selectively infiltrating the putatively symptomatic joint</p><p>completely relieves the patient of the pain.</p><p>On the basis of recent research, these criteria have evolved</p><p>for a variety of reasons. Diagnostic injections must be per-</p><p>formed under image intensifier control, because “blind” injec-</p><p>tions rarely succeed in placing injectate within the SIJ</p><p>cavity.17,18 An optimal technique of injection was established in</p><p>1992,19 and is also described in the first and second editions of</p><p>the practice guidelines issued by the Spine Intervention Society</p><p>(SIS).5 Because false-positive responses to single diagnostic</p><p>blocks into synovial joints are common,20 comparative or pla-</p><p>cebo-controlled blocks are now considered essential before a</p><p>diagnosis of SIJ-mediated pain is confirmed.</p><p>SELECTION CRITERIA FOR INTERVENTIONAL</p><p>DIAGNOSTIC TESTING FOR SIJ PAIN</p><p>The task for the primary and secondary care clinician is to</p><p>decide whether a patient should be subjected to interventional</p><p>diagnostic testing of the SIJ, or whether the source of pain lies</p><p>elsewhere. Diagnostic reasoning algorithms have been pub-</p><p>lished for SIJ pain diagnosis as a discrete clinical entity,21,22</p><p>and as a diagnosis embedded into differential diagnostic pro-</p><p>cedures for interventional spine physicians.5 The 2004 SIS</p><p>From the AUT University, Akoranga Campus, North Shore, Auckland,</p><p>New Zealand and private practice in Christchurch, New Zealand.</p><p>The author declares that they have nothing to disclose.</p><p>For reprint requests, or additional information and guidance on the</p><p>techniques described in the article, please contact Mark Laslett,</p><p>NZRPS, PhD, FNZCP, Dip.MT, Dip.MDT, at mark.laslett@xtra.co.nz</p><p>or by mail at 7 Baltimore Green, Shirley, Christchurch 8061, New</p><p>Zealand. You may inquire whether the author(s) will agree to phone</p><p>conferences and/or visits regarding these techniques.</p><p>Supplemental Digital Content is available for this article. Direct URL</p><p>citations appear in the printed text and are provided in the HTML and PDF</p><p>versions of this article on the journal’s website, www.techortho.com.</p><p>Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.</p><p>SYMPOSIUM</p><p>Techniques in Orthopaedics$ � Volume 00, Number 00, 2018 www.techortho.com | 1</p><p>Copyright r 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.</p><p>mailto:mark.laslett@xtra.co.nz</p><p>http://www.techortho.com</p><p>guidelines were updated in the second edition, but were less</p><p>complete with regard to diagnosis of SIJ pain in my opinion.</p><p>Certainly, updating was required because published evidence</p><p>since then has strengthened some aspects of the clinical</p><p>examination, and has also described increasing complexity of</p><p>the issue. The most recent perspective from the SIS may be</p><p>found in recent papers.13,15,23,24</p><p>What follows is a summary of history and physical</p><p>examination findings needed to identify patients with a high</p><p>probability of having pain arising from the SIJ, and who may</p><p>reasonably be subjected to controlled and guided intra-articular</p><p>SIJ blocks.</p><p>THE CLINICAL HISTORY</p><p>The one essential item from the clinical history is a pain</p><p>drawing. I prefer a pain drawing using colors.25 The exact</p><p>location of the dominant complaint should be documented. The</p><p>pain drawing should provide an answer to the question: “Is the</p><p>pain entirely caudal to L5?” Figures 1 and 2 provide 2 examples</p><p>of patients with confirmed SIJ pain as an example of possible</p><p>variations. Moreover, widespread pain and/or multiple dramatic</p><p>annotations suggest psychosocial distress26 and prompts cau-</p><p>tion in interpreting physical test results.</p><p>The following are items needed to establish a baseline</p><p>against which diagnostic and</p><p>ultimately therapeutic intervention</p><p>results may be compared:</p><p>(1) A measure of pain intensity, such as a 100 mm VASs for</p><p>current, worst, and lowest intensity</p><p>(2) A validated measure of disability. I prefer to use the</p><p>Roland-Morris Disability Questionnaire. A version relevant</p><p>to your own culture and language may be downloaded from</p><p>here: www.rmdq.org/.</p><p>(3) At least one answer to the question: “What is the best</p><p>position or activity for your pain?”</p><p>(4) Recommended but not essential: completion of the Central</p><p>Sensitization Index Questionnaire.27,28 Scores over 40 indicate</p><p>that false-positive SI provocation tests are more likely.</p><p>THE PHYSICAL EXAMINATION</p><p>Palpation-based tests and other tests of biomechanical</p><p>symmetry of form and function, have not been validated, except</p><p>for the occasional study of reliability.29,30 The only tests that</p><p>have been shown to possess consistent reliability and useful</p><p>diagnostic accuracy in relation to a reference standard for SIJ</p><p>pain are the provocation tests.</p><p>PAIN PROVOCATION SIJ JOINT TESTS</p><p>Pain provocation tests are those that stress the target</p><p>structures and provoke the usual or familiar pain of which the</p><p>patient complains. The key SIJ tests (distraction, compression,</p><p>thigh thrust, the Gaenslen, and sacral thrust) have been described</p><p>in detail previously21,31 and are reproduced in Figures 3–9. The</p><p>drop or bump test (Fig. 9) described by Robinson et al32 is</p><p>reliable but has not yet been assessed for validity in a diagnostic</p><p>accuracy study. A video (Supplemental Digital Content 1,</p><p>http://links.lww.com/TIO/A20) of the clinical tests is available.</p><p>The FABER test has also been validated,33 but is as much</p><p>a test of hip pain and function, as it is a test of the SIJ. It may be</p><p>FIGURE 1. Patient-completed pain drawing and arthrogram for a patient with traumatic origin SIJ pain confirmed by comparative SIJ</p><p>blocks. SIJ indicates sacroiliac joint.</p><p>Laslett Techniques in Orthopaedics$ � Volume 00, Number 00, 2018</p><p>2 | www.techortho.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.</p><p>Copyright r 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.</p><p>http://www.rmdq.org/</p><p>http://links.lww.com/TIO/A20</p><p>substituted for any one of the tests I report on here, but is not</p><p>one I personally use frequently.</p><p>It is clear from our experience and research that the SIJ</p><p>provocation tests are often false positive. This is not the death</p><p>sentence for clinical diagnostic testing that is often assumed,</p><p>and may be managed using clustering techniques and appro-</p><p>priate diagnostic reasoning. The basic principle in the clinical</p><p>reasoning stems from a single fact. SIJ pain, when present, is</p><p>typically an isolated painful pathology. That is, it is uncommon</p><p>for SIJ pain to be concurrently present with other painful ana-</p><p>tomic sites. From our own data, only 2 of 216 consecutive cases</p><p>had confirmed SIJ pain and another pathoanatomic diagnosis,</p><p>one discogenic pain and the other spinal stenosis.34 The prac-</p><p>tical utility of this observation is that if there is another valid</p><p>diagnosis for the patient’s pain, then it is highly improbable that</p><p>the SIJ is also a source of pain, and that any positive pain</p><p>provocation tests are likely false positive. If no other source of</p><p>pain is identified, then the provocation tests should be consid-</p><p>ered as important indicators of SIJ pain, with increasing con-</p><p>fidence associated with increased numbers of positive provo-</p><p>cation tests. The minimum number of positive provocation tests</p><p>required to justify invasive confirmatory diagnostic testing of</p><p>the SIJ is 2, with greater confidence when ≥ 3 are positive.</p><p>THE MCKENZIE REPEATED MOVEMENT</p><p>ASSESSMENT FOR CENTRALIZATION AND</p><p>DIRECTIONAL PREFERENCE</p><p>The centralization phenomenon was first formally descri-</p><p>bed by McKenzie35 in 1981, and research into its relevance</p><p>started shortly thereafter.36–38 Directional preference was first</p><p>described in 1991,39 and both are reliable clinical signs when</p><p>the physical examination is conducted by trained clinicians.40,41</p><p>The close relationship between the 2 phenomena has been</p><p>FIGURE 2. Patient-completed pain drawing for patient with sacroiliac joint pain of spondyloarthropathy origin, supported by NaF PET/</p><p>CT imaging. CT indicates computed tomography; NaF, sodium fluoride; PET, positron emission tomography.</p><p>Techniques in Orthopaedics$ � Volume 00, Number 00, 2018 Clinical Diagnosis of Sacroiliac Joint Pain</p><p>Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. www.techortho.com | 3</p><p>Copyright r 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.</p><p>explored in detail.42 The relationship between centralization</p><p>and discogenic pain was hypothesized by McKenzie in his</p><p>original 1981 text and was established in 1997.43 The most</p><p>recent study used stricter and simpler criteria for centralization,</p><p>and resulted in the phenomenon being established as having</p><p>near perfect specificity to disk stimulation during controlled</p><p>provocation discography in nondistressed patients, and still</p><p>respectable specificity exceeding 80% even in the most disabled</p><p>and distressed individuals.44 This means that a simple clinical</p><p>assessment can identify a subset of cases with discogenic pain,</p><p>and who are most unlikely to have isolated SIJ pain. There is a</p><p>catch though. Training in the assessment and interpretation of</p><p>patient responses to repeated movement testing is vitally</p><p>important. The examination of repeated movements is simple in</p><p>principle and highly standardized. That is the basis for its</p><p>reliability. This requires training, practice, and experience.</p><p>Certification in this clinical assessment is widely available in</p><p>almost all developed countries from the McKenzie Institute</p><p>International (www.mckenzieinstitute.org/). This video (Sup-</p><p>plemental Digital Content 1, http://links.lww.com/TIO/A20)</p><p>gives some detail on what the Mckenzie system is:</p><p>www.youtube.com/watch?v=Gwrt9deGUTQ. Those who are</p><p>seeking trained clinicians can acquire the needed information</p><p>from this source. I declare that I have no conflict of interest in</p><p>promoting this training. I receive no tangible benefit from, have</p><p>had no contact with, nor involvement in the McKenzie Institute</p><p>since 1997, and so can recommend this training, as I recom-</p><p>mend the SIS’ education in interventional diagnostic procedures</p><p>(www.spineintervention.org/). The need for a competent repeated</p><p>movement assessment lies in the fact that discogenic pain, as</p><p>revealed by centralization and directional preference, is common.</p><p>At least 25% of chronic back pain samples centralize,44 and</p><p>some estimate the prevalence as high as ≥ 50% in primary</p><p>care environments.45 A brief overview of the McKenzie system</p><p>and assessment is available at: www.youtube.com/watch?v=</p><p>Gwrt9deGUTQ&t=7s.</p><p>Figures 10–17 show the basic standardized test move-</p><p>ments for the repeated movement assessment. Not all are used</p><p>FIGURE 3. The distraction test (testing right and left SIJ simulta-</p><p>neously). Vertically oriented pressure is applied to the anterior</p><p>superior iliac spinous processes directed posteriorly, distracting</p><p>the SIJ.</p><p>FIGURE 4. The thigh thrust test (testing the left SIJ). The sacrum</p><p>is fixated against the table with the left hand, and a vertically</p><p>oriented force is applied through the line of the femur</p><p>directed posteriorly, producing a posterior sheering force at the</p><p>SIJ.</p><p>FIGURE 5. The Gaenslen test (testing the left SIJ in posterior</p><p>rotation and the right SIJ in anterior rotation). The pelvis is</p><p>stressed with a torsion force by a superior/posterior force applied</p><p>to the left knee and a posteriorly directed force applied to the</p><p>right knee.</p><p>FIGURE 6. The Gaenslen test (testing the right SIJ in posterior</p><p>rotation and the left SIJ in anterior rotation). The pelvis is stressed</p><p>with a torsion force by a superior/posterior force applied to the</p><p>right knee and a posteriorly directed force applied to the left</p><p>knee.</p><p>Laslett Techniques in Orthopaedics$ � Volume 00, Number 00, 2018</p><p>4 | www.techortho.com Copyright © 2018 Wolters</p><p>Kluwer Health, Inc. All rights reserved.</p><p>Copyright r 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.</p><p>http://www.mckenzieinstitute.org/</p><p>http://links.lww.com/TIO/A20</p><p>http://www.youtube.com/watch?v=Gwrt9deGUTQ</p><p>http://www.spineintervention.org/</p><p>http://www.youtube.com/watch?v=Gwrt9deGUTQ&t=7s</p><p>http://www.youtube.com/watch?v=Gwrt9deGUTQ&t=7s</p><p>in any given patient. These tests are dynamic, and video or live</p><p>demonstration is best to show how they are used, analyzed, and</p><p>reported on in determining whether symptoms may be cen-</p><p>tralized, or whether there is a repeatable directional preference</p><p>in pain intensity and movement obstruction. In principle, the</p><p>testing is very simple. In practice, however, interpretation and</p><p>analysis is a learned skill like any other. Unsurprisingly, those</p><p>who are doing this test procedure routinely and often, get more</p><p>consistent and reliable results.</p><p>AN ALGORITHM TO IDENTIFY PATIENTS</p><p>SUITABLE FOR INTERVENTIONAL TESTING</p><p>FOR SIJ PAIN</p><p>The basic reasoning process is simple enough and con-</p><p>forms to the basic principle:</p><p>Provocation SIJ test results are ignored if there is another</p><p>clear diagnosis available to explain pain that is dominant</p><p>below the level of L5 and above the gluteal fold.</p><p>The algorithm (Fig. 18) starts with a simple “test” based</p><p>on an answer to the question: “where is the dominant pain</p><p>location?” If the patient identifies a dominant pain location in</p><p>the lower extremity or above the sacrum, the probability that an</p><p>SIJ pain source is quite low47 and the source of pain should be</p><p>sought elsewhere unless there is good reason for the SIJ to</p><p>remain in the differential diagnosis list. If the pain is dominant</p><p>above the sacrum, then discogenic or facetogenic pain should</p><p>be considered, not the SIJ. If pain is dominant at or below the</p><p>gluteal fold level, radicular syndrome or the hip joint should be</p><p>considered, rather than the SIJ.</p><p>The next step is also simple. Identification of radicular syn-</p><p>drome (ie, radicular pain with or without radiculopathy) is routine</p><p>for all health care practitioners. The minimum requirements are:</p><p>(1) The presence of significant radicular quality pain (sharp,</p><p>twinging pain in a narrow band, usually conforming to a</p><p>myotome) below the gluteal fold.</p><p>(2) The radicular quality pain is enhanced in the performance</p><p>of a neural tension test (straight leg raise test or femoral</p><p>nerve test), which is also limited in range.</p><p>(3) Radiculopathy (key muscle weakness, reflexopathy, or skin</p><p>anesthesia in dermatomal distribution) is not essential in</p><p>this identification, but, when present, strengthens the</p><p>diagnosis of radicular syndrome.</p><p>Identification of radicular syndrome should guide the</p><p>practitioner to hi-tech imaging (computed tomography/</p><p>magnetic resonance imaging) to identify the source of nerve</p><p>root irritation or compression, not to investigation of the SIJ.</p><p>The next step is to answer the question “can the symptoms</p><p>be made to centralize, or is there a clear directional preference</p><p>to pain and movement obstruction, identified by a McKenzie</p><p>repeated movements assessment?” If the answer is “yes,” then</p><p>the pain is likely discogenic, and SIJ test results should be</p><p>ignored as probably false positive. Where a clinician with the</p><p>appropriate training and experience in this assessment is not</p><p>available, the astute clinician may get a hint of this pain</p><p>behavior pattern from the history. If flexion activities (sitting,</p><p>especially prolonged sitting) and repeated or sustained forward</p><p>bending consistently produce or increase referred pain, and,</p><p>extension activities (like walking or lying prone) consistently</p><p>abolish referred pain, a directional preference to extension may</p><p>be suspected. This is no substitute for the formal assessment</p><p>though, because over 10% of those with a directional preference</p><p>have a flexion preference, not an extension one.39 In addition,</p><p>about 10% of cases with an extension preference, need to have a</p><p>lateral shift corrected48 before extension procedures, to achieve</p><p>centralization. For those clinicians without access to a skilled</p><p>repeated movement assessment, I exhort you to either undergo</p><p>the training yourself (it is not difficult) or develop a proper</p><p>relationship with a clinician who does have the experience and</p><p>training. You will not be disappointed.</p><p>From this point, the probability that the SIJ structures are</p><p>involved in the pain is moderately high, and interpretation of</p><p>the results of the provocation tests is appropriate and necessary.</p><p>This is a 3-stage process, one of ruling out and the others of</p><p>ruling in. First, the question should be: “Do SIJ provocation</p><p>tests provoke typical pain?” If they do not, even with significant</p><p>force applied, SIJ pain is highly unlikely. There are exceptional</p><p>circumstances though. In some cases of spondyloarthropathy,</p><p>the patient may be completely asymptomatic at the time of your</p><p>assessment. In this situation, a decision cannot be arrived at. A</p><p>repeated movement assessment is pointless too, and a follow-up</p><p>assessment during an active phase is required. If the patient is</p><p>symptomatic and no tests are positive, a definite rule-out of SIJ</p><p>FIGURE 7. The compression test (testing right and left SIJ). A</p><p>vertically directed force is applied to the iliac crest directed toward</p><p>the floor, that is, transversely across the pelvis, compressing the</p><p>SIJs.</p><p>FIGURE 8. The sacral thrust test (testing right and left SIJ simul-</p><p>taneously). A vertically directed force is applied to the midline of</p><p>the sacrum at the apex of the curve of the sacrum, directed</p><p>anteriorly, producing a posterior sheering force at the SIJs.</p><p>Techniques in Orthopaedics$ � Volume 00, Number 00, 2018 Clinical Diagnosis of Sacroiliac Joint Pain</p><p>Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. www.techortho.com | 5</p><p>Copyright r 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.</p><p>pain is possible. If only 1 test is painful, SIJ pain is highly</p><p>unlikely, and there must be compelling reasons to further pur-</p><p>sue SIJ pain diagnostic testing.</p><p>If 2 of 4 tests (distraction, compression, thigh thrust, or</p><p>sacral thrust) provoke typical pain, the diagnostic accuracy in</p><p>relation to a single screening SIJ intra-articular block is known:</p><p>sensitivity, specificity, positive, and negative likelihood ratios</p><p>are 88%, 78%, 4, and 0.16, respectively.49 In an assumed</p><p>prevalence of 20%, the posttest probability of a positive</p><p>response to a screening block may be calculated as 50%. Note</p><p>that these estimates are for the ≥ 2 composite out of context of</p><p>FIGURE 10. The standardized minimum set of test movements</p><p>for identifying centralization and directional preference. The</p><p>repeated movement assessment of McKenzie and May.46 Flexion</p><p>in standing test.</p><p>FIGURE 11. The standardized minimum set of test movements</p><p>for identifying centralization and directional preference. The</p><p>repeated movement assessment of McKenzie and May.46 Exten-</p><p>sion in standing test.</p><p>FIGURE 9. The bump or drop test (testing the right sacroiliac joint). The patient raises the heel from the floor, taking near full</p><p>bodyweight, then drops the heel to the floor with a bump, retaining the knee in extension at all times, producing a cranially directed</p><p>sheer force of the right ilium on the sacrum.</p><p>Laslett Techniques in Orthopaedics$ � Volume 00, Number 00, 2018</p><p>6 | www.techortho.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.</p><p>Copyright r 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.</p><p>the algorithm being used here. Hence, within the algorithm, the</p><p>removal of false-positive tests should produce much higher</p><p>accuracy values. Some consider a screening block justifiable as</p><p>the reference standard diagnostic procedure for sacroiliac joint</p><p>pain, but modern methodology demands a either a placebo or</p><p>comparative control.13,50</p><p>Within the context of this algorithm, if ≥ 3 provocation</p><p>tests provoke typical pain, the probability that a patient will</p><p>respond positively to the fully</p><p>controlled SIJ diagnostic</p><p>injection standard is considerably higher. By just removing</p><p>false-positive test responses in cases whose pain can be</p><p>centralized, we do have accuracy data. Sensitivity, specificity,</p><p>and positive and negative likelihood ratios for this composite</p><p>are: 91%, 87%, 7.0, and 0.11, respectively.22 Prevalence in</p><p>that sample was 32.4%; hence, posttest probability of a pos-</p><p>itive response to a double block is calculated as 77%.</p><p>Although no data exist for this assertion, removal of cases</p><p>with other diagnoses explaining the patient’s complaint of</p><p>buttock pain, is likely to reduce the false-positive rate further.</p><p>This has not yet been studied.</p><p>There are several caveats that need to be stated when</p><p>evaluating this clinical reasoning algorithm:</p><p>FIGURE 12. The standardized minimum set of test movements</p><p>for identifying centralization and directional preference. The</p><p>repeated movement assessment of McKenzie and May.46 Side</p><p>gliding in standing test.</p><p>FIGURE 13. The standardized minimum set of test movements</p><p>for identifying centralization and directional preference. The</p><p>repeated movement assessment of McKenzie and May.46 Side</p><p>gliding in standing with manual overpressure for lateral shift</p><p>correction.</p><p>FIGURE 14. The standardized minimum set of test movements</p><p>for identifying centralization and directional preference. The</p><p>repeated movement assessment of McKenzie and May.46 Flexion</p><p>in lying test.</p><p>FIGURE 15. The standardized minimum set of test movements</p><p>for identifying centralization and directional preference. The</p><p>repeated movement assessment of McKenzie and May.46 Exten-</p><p>sion in lying test.</p><p>Techniques in Orthopaedics$ � Volume 00, Number 00, 2018 Clinical Diagnosis of Sacroiliac Joint Pain</p><p>Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. www.techortho.com | 7</p><p>Copyright r 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.</p><p>(1) The data upon which diagnostic accuracy statistics are</p><p>calculated, are derived from a sample with high levels of</p><p>distress and disability.</p><p>(2) Some patients were so disabled that the full assessment</p><p>could not be carried out and so were not included in the</p><p>analysis.</p><p>(3) Technically, applying these diagnostic accuracy statistics to</p><p>a different setting will almost certainly produce different</p><p>accuracy values. I believe diagnosis is easier in less</p><p>distressed samples, but that is an opinion only, based on</p><p>experience, not published data.</p><p>(4) Only part of the algorithm has been independently</p><p>validated.33 That is, where the composite of ≥ 3 provoca-</p><p>tion tests are taken out of context of a full clinical</p><p>assessment, as described here.</p><p>In addition to the stated caveats, there are qualifiers to this</p><p>algorithm that should be acknowledged. Some strengthen the</p><p>probability that the SIJ is the source of pain in any given</p><p>patient, whereas others reduce the confidence that a clinical</p><p>diagnosis can be made.</p><p>The following items from the history will increase the</p><p>probability that the SIJ is involved in the patient’s complaint of</p><p>lumbopelvic pain:</p><p>(1) Pain commencing during pregnancy or in the immediate</p><p>few months after vaginal delivery of a baby. Using criteria</p><p>similar to those described here, a study of Swedish women</p><p>in the 12th to 18th week of pregnancy revealed that 62%</p><p>had some form of lumbopelvic pain. Of them, 54% satisfied</p><p>the ≥ 3 positive pain provocation test and noncentralization</p><p>rule, 17% had centralizable symptoms but</p><p>Sacroiliac joint: pain referral</p><p>maps upon applying a new injection/arthrography technique. Part II:</p><p>clinical evaluation. Spine. 1994;19:1483–1489.</p><p>5. Bogduk N. 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