Are sacroiliac joint mobility tests reliable?

In daily practice sacroiliac joint pain is a common complaint. There are two types of tests to either 1. provoke pain or 2. test dysfunction/mobility of the sacroiliac joint.

Up until today there is no consensus whether there is actually sacroiliac joint movement. Some 20 years ago some systematic reviews on the reliability and validity of sacroiliac joint mobility tests were published. They showed that the tests were not reliable or valid.

In the meantime new tests have been developed and the systematic review I will discuss today has the aim to update the previous systematic reviews. Are the recommendations still in place?

METHOD

For this systematic review the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. Studies reporting on clinimetric properties of sacroiliac joint mobility tests which can be used in daily practice were included. The tests had to be tested on; adults with non-specific low back pain, pelvic girdle pain and/or sacroiliac joint pain.

The Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) was used to assess quality of the studies. With the COSMIN you can score for instance reliability, content validity, structural validity, criterion validity and responsiveness. Each item is scored on a 4 point scale: excellent, good, fair and poor. In this systematic review they only selected studies with a fair or higher overall quality score were considered for data extraction.

The measurement properties of the tests were put in a best evidence synthesis. This is based on the adjusted Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE Working group).

RESULTS

Twelve studies were included and assessed. Eleven studies described the reliability and two the validity of sacroiliac joint mobility tests. Reliability, validity definitie

Three reliability studies were of fair methodological quality and therefor included. All three reported on inter-tester and two on intra-tester reliability. The reliability of eight mobility tests were described and one of a cluster of four.

Which tests are we talking about (some have links to YouTube films):

1. Click-clack test. The patient is sitting upright on the bench. The patient moves from lordosis to kyphosis in the lumbar spine. The examiner palpates the speed of each Posterior Superior Iliac Spine (PSIS). The test is positive if one of the PSIS moves slower from cranial to caudal.
2. Standing flexion test
3. Seated flexion test
4. Gillet test
5. Prone knee flexion test
6. Heel-bank test. The patient is sitting upright on the bench. The patient raises one knee and places the heel on the bench without using the hands. The ability to raise the leg is scored on a 5-point scale.
7. Abduction test. The patient is in side-lying. Both hips and knees are flexed. The patient is asked to lift to top leg 20 cm in abduction. The ability to lift the leg is scored on a 5-point scale.
8. Thumb-posterior superior iliac spine (PSIS) test. The patient is sitting upright on the bench. The arms are crossed. The examiner palpates PSIS. The position of the PSIS is scored.

The authors classified the level of evidence as low (inter-tester reliability). This is due to the fact that of each test only one study was well enough performed (fair) to be included in the systematic review. The exception was the Gillet test. But for the Gillet test the level of evidence was inconsistent.

The study examining the cluster of the Gillet test, standing flexion test, seated flexion test and the prone knee flexion test showed higher reliability (fair to moderate agreement for four positive tests). But we have to keep in mind that this is based on only one study.

Clinical implication for (pelvic) physiotherapists

The review I have discussed today hasn’t found validity studies with at least a fair methodology. However, the authors hypothesise that palpation of sacroiliac joint mobility might be impossible because:

1. The motion of the sacroiliac joints is very very small
2. Variation in anatomy of the sacroiliac joint
3. Soft tissue might distort palpation accuracy

This systematic review is an update of a 20 year old systematic review.  It confirmed that there is no need to adjust the present recommendation not to use sacroiliac joint mobility tests in clinical practise.

My personal opinion

Besides the recommendation not to use these tests and the knowledge that sacroiliac joint mobility cannot be tested clinically I would also like to state that it is very important that physiotherapists use the right words in communicating with the patient. So for example don’t use words like: stiff, limited or mobility because this just cannot be tested.

Reference: 

Klerx SP, Pool JJM, Coppieters MW, Mollema EJ, Pool-Goudzwaard AL. Clinimetric properties of sacroiliac joint mobility tests: A systematic review. Musculoskelet Sci Pract. 2019 Nov 9:102090. doi: 10.1016/j.msksp.2019.102090. [Epub ahead of print]