Examination and Treatment of the SI Joint

The SI joint happens to be one of the most controversial areas in the body. We can’t necessarily completely agree on what type of a joint it is. Most people think it is a diarthrodial joint. Most people think it does have synovial fluid and a synovial capsule. The other thing we disagree on to some degree is how many axes of motion there are and therefore what kind of motion there is in the joint.

The prevalence of issues with the SI joint has also been somewhat disagreed upon. It has been reported in the literature at anywhere from 15 to 40 percent.

A lot of this is thought to be due to convergence. Convergence is the fact that pain in one area can cause pain in another area.

What’s interesting about the SI joint is that the synovial capsule posteriorly is actually thought to be discontinuous. The reason that’s important is that if the SI joint gets extremely full of fluid, that fluid actually can leak outside the posterior capsule and can cause the surrounding structures to get irritated.

One thing you may be want to be cautious of when you differentially diagnose the SI joint is that you don’t automatically exclude the SI joint because there’s pain radiating below the knee. It could be the SI joint, as well.

The SI joint is kind of a wedge–shaped joint, which provides a unique structure and unique orientation of the joint as well as unique movement.

The other thing that’s kind of controversial and leads to some difficulty in diagnosing SI joint issues is the innervation of the SI joint.

Some of the biomechanics of the SI joint have been described to include both rotatory motion and translatory motion. Although there is rotatory motion and translatory motion of the SI joint, there isn’t very much motion. The SI joint does move; it just doesn’t move very much.

Maybe the biggest thing to think about biomechanically here is that the SI joint is part of a lumbar spine, pelvis and hip complex. All the motions of these areas are interrelated. Probably the biggest thing to consider when all of these motions are interrelated is how they work together.

As far as examination of the SI joint, what is probably the best approach? The best approach that I would suggest is using the SI joint as a diagnosis of exclusion. What I mean by that is that you should try to rule out the lumbar spine first, and then you should try to rule out the hip.

The other thing to consider is that an examination of the SI joint, like every other part of the body, is a comprehensive examination. Make sure that you look at the subjective history and the objective history.

Through the whole entire examination, look for both sensitive and specific characteristics. Throughout this examination, we will talk about sensitivity and specificity. Sensitivity is trying to rule out the condition. So a highly sensitive test helps rule out the condition; a highly specific test helps rule in the condition.

This educational film will explore the Evaluation and Treatment of the SI joint. An evidence based approach is taken throufh a methodical process. Join me on this journey and start to master your examination and treatment of the SI Joint.

Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS is an assistant professor of physical therapy at Duke University Medical Center. As a clinician Dr. Reiman has over 20 years of experience in assessing, rehabilitating, and training athletes, clients, and patients at various levels of ability. He received his doctoral degree in physical therapy from MGH Institute of Health Professions in 2007. In addition to his certifications as an athletic trainer and strength and conditioning specialist, Dr. Reiman is a manual therapy fellow through the American Academy of Orthopaedic and Manual Physical Therapists (having completed a 2 and one year fellowship program), is a USA Weightlifting level 1 coach and a USA Track and Field level 1 coach. Dr. Reiman has co-written the only textbook on functional testing, Functional Testing in Human Performance, written eight book chapters on orthopedic examination/intervention and training for strength, power, and endurance. He has also written multiple articles in such journals as the American Journal of Sports Medicine, Journal of Orthopedic and Sports Physical Therapy, and Journal of Sport Rehabilitation, as well as having served as special guest editor for a special issue on the hip joint in the Journal of Sport Rehabilitation. Dr. Reiman currently serves on the editorial board for the Journal of Sport Rehabilitation and is a reviewer for multiple orthopedic and sports related journals. Dr. Reiman presents on various levels of assessment and treatment methods at national, regional, and local conferences and actively participates in research regarding various testing methods for orthopedic examination-intervention and human performance. His current research and presentation interests focus on performance enhancement, low back/hip pain, and evidence based examination-intervention of the hip joint. He continues to practice clinically on various sports and orthopedic-related injuries. He is a member of the American Physical Therapy Association, National Athletic Trainers Association, National Strength and Conditioning Association, USA Weightlifting Association, and USA Track and Field Association

• Apply a differential diagnosis approach to a thorough examination of the SI joint while ruling out lumbar spine and hip disorders.
• Identify the evidence based information that supports the rationale for selected examination and treatment techniques for the SI joint.
• Perform SI joint provocation tests.
• Recognize the appropriate tests to identify muscle dysfunction motor control dysfunction and /or pelvic instability.
• Identify when to use SI joint movement tests and perform them properly.
• Perform manual therapy mobilizations and muscle energy techniques for effective treatments of common SI disorders such as: anterior rotated innominate, posterior rotated innominate, outfare dysfunction, inflare dysfunction, and downslip.
• Develop effective progressive exercise programs for the management of SI dysfunction.

• Repeated Motions (Flexion and Extension)of Lumbar Spine
• Posterior–Anterior Glide Assessment for Facet Joint Dysfunction
• Extension Rotation Test for Facet Joint Dysfunction

• Patellar–Pubic Percussion Test
• Fulcrum Test of Femur
• Heel Strike Test
• Resisted SLR Test
• FADDIR (Flexion–Adduction–Internal Rotation)Test

• Thigh Thrust Test
• Gaenslen’s Test
• Distraction Test
• Compression Test
• Sacral Thrust Test
• The Flick Test

• Trendelenburg Sign
• The Standing Lunge Test
• Active Straight Leg Raise Test
• Single Leg Bridge Test
• Standing Flexion Test
• Standing Stork/March Test
• Supine to Sit Test
• Assessment for Sacral Flexion Movement with Prone Press–Up

• Palpation of Inferior Lateral Angle of Sacrum
• Palpation of Sacrotuberous Ligament
• Palpation of Pubic Symphysis

• Mobilization for Anteriorly Rotated Innominate
• Mobilization for Posteriorly Rotated Innominate
• Mobilization for Outflare Dysfunction
• Mobilization for Inflare Dysfunction
• Mobilization/Manipulation for Upslip Dysfunction
• Mobilization for Downslip Dysfunction
• SI Regional Grade V
• Side Lying SI Grade V

• Learn Sacral Mobilization Techniques
• Muscle Energy Technique for Anteriorly Rotated Innominate
• Muscle Energy Techniques for Posteriorly Rotated Innominate
• Muscle Energy Technique for Outflare Dysfunction
• Muscle Energy Technique for Inflare Dysfunction
• Muscle Energy Technique for Left on Left Sacral Dysfunction
• Muscle Energy Technique for Right on Left Sacral Dysfunction

• Clam Exercise
• Hip Abduction Exercise
• Bilateral and Unilateral Bridge Exercise
• Bilateral and Unilateral Bridge Exercise–Lying on Physioball
• Bilateral Bridging on Physioball–Knees Straight
• Bilateral Bridging on Physioball–Knees Bent
• Bird Dog Exercise
• Lunge Exercise Variations
• Unilateral Mini–Squat Exercise
• Single Limb Squat Exercise
• Single Limb Deadlift Exercise
• Forward Step–Up Exercise
• Side–Bridge Exercise

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