1575
BRIEF-REPORT
__-
CLINICAL EXAMINATION OF THE SACROILIAC JOINTS:
A PROSPECTIVE STUDY
A. S. RUSSELL, W. MAKSYMOWYCH, and S. LECLERCQ
Examination of the peripheral joints is a rela-
tively standard and uncomplicated process, because
these joints can be seen and palpated. In contrast, the
sacroiliac joints can be located by their surface mark-
ings, but they cannot be directly examined. These are
irregular plane joints, the most superficial aspect of
which is approximately 2 cm from the surface. Joint
assessment is therefore indirect, and numerous tech-
niques have been recommended, ranging from direct
pressure to various maneuvers thought to apply shear
stresses to the articular surfaces and periarticular
tissues.
Seven eponymous tests were reviewed at a
meeting in 1957, but even at that time, doubt was cast
on their validity (1). At the same meeting, yet other
maneuvers were described and rather greater confi-
dence was placed in the results (2). The uncertainty
remains. Moll, writing in a recent textbook, describes
several techniques of sacroiliac examination without
making any specific recommendations (3). In “physi-
cal examination of the joints,” sacroiliac stressing by
flexion of one hip and hyperextension of the other is
described as the optimum way to look for inflamma-
tion (4). This is also recommended by Partridge ( 5 ) , as
well as by Bluestone (6). In the latter textbook,
Bluestone also recommends direct compression. Such
anteroposterior and lateral pelvic compression is spe-
.-- ..
From the Rheumatic Disease Unit, Department of Medi-
cine, University of Alberta, Edmonton, Alberta, Canada.
Address reprint requests to A. S . Russell, FKCP(C), Rheu-
matology and Clinical Immunology, 9-1 12 Clinical Sciences Build-
ing, The University of Alberta. Edmonton, Alberta T6G 2G3,
Canada.
Submitted for publication February 19, 1981; accepted in
revised form May 27, 1981.
Arthritis and Rheumatism, Vol. 24, No. 12 (December 1981)
cifically recommended by Boyle and Buchanan (7).
Conversely, the most recent two-volume Textbook of
Rheuntatofogy avoids discussion or even mention of
any such maneuvers (8).
The current study was prompted partly because
of our clinical impression that none of the recommend-
ed tests were of value and also because of suggestions
to the contrary made by referees of some of our recent
publications. We have undertaken a prospective trial
to determine whether any of the commonly used or
recommended techniques of sacroiliac joint assess-
ment might be of value in distinguishing between
ankylosing spondylitis and other noninflammatory
back diseases. Our conclusion is that none have any
useful discriminatory function.
Patients and Methods. Patients who had persis-
tent low back pain of over 6 months duration but were
otherwise unselected were included in the study. They
were examined by one of us using the assessments
described below. In an attempt to minimize the possi-
bility of bias, assessments were performed without
knowledge of radiologic or laboratory features. The
final diagnosis was based on conventional criteria, and
patients were designated as having ankylosing spondy-
litis according to criteria for definite or classic disease.
An additional group of 23 patients already known to
have classic ankylosing spondylitis and who fitted the
above symptom criteria for active disease were also
studied. The two groups of patients with ankylosing
spondylitis comprised all the patients with definite
radiologic sacroiliac abnormalities (grade I1 or great-
er). A further subgroup of patients with either evident
Reiter’s syndrome or with backache and marked
morning stiffness, but normal sacroiliac joints radio-
1576
Table 1. Assessment of tests designed to stress the sacroiliac joints
MUSCU~O-
ligamentous Lumbar disc
back pain disease
Total no. subjects 57 4 I1
Malelfemale 34/33 212
Schober’s test (mean cm) 4.4 5.0
Age (mean years) 43 37
Stress test*
Direct sacroiliac pressure 41 I 4
Sacral pressure 6 0
L3-S1 midline pressure 24 3 2
Hip extension I5 2 3
Anterior posterior compression 9 0
Lateral compression 6 0
* Number positive in each diagnostic category.
logically, were designated as having presumptive in-
flammatory sacroiliac disease.
The purpose of the study was to determine the
relationship of the tests to ankylosing spondylitis.
Little attempt has therefore been made to classify the
final diagnoses in those patients who were thought not
to have inflammatory disease of the sacroiliac joints.
This group is designated as having “musculo-ligamen-
tous backache,” and, although undoubtedly a diverse
group, all had radiologically normal sacroiliac joints.
No effort was made to distinguish or subgroup patients
with predominant influences of one particular type, for
example, postural or psychogenic factors. A few pa-
tients in whom subsequent myelography confirmed the
presence of a prolapsed disc suspected on clinical
grounds have been indicated in Table I .
Stress tests. 1) Hip extension test: This was
performed as described in detail elsewhere ( 2 ) . Briefly,
the patient lies supine with one hip fully flexed; the
other is then hyperextended over the side of the
examining couch. (Patients with clinically evident hip
joint disease were not included.) This was performed
on both sides, and a complaint of low back pain by the
patient was designated as a positive response.
2) Anteroposterior pelvic pressure: With the
patient supine on the examining couch, firm posterior
pressure is applied to both anterior superior iliac
spines and the anterior iliac crest. Low back pain of
central, unilateral, or bilateral distribution was a posi-
tive response.
3) Lateral pelvic compression: With the patient
lying on each side in turn, firm downward pressure is
applied to the contralateral ilium.
Direct pressure. 1) Over the sacroiliac joint:
Firm pressure is applied over the ligaments of both
BRIEF REPORT
Preselected
“Sacroiliac Ankylosing ankylosing
inflammation” spondylitis spondylitis
15 26
813 916 2014
4.1 3.6 3.6
29 35 41
2 4
0 I I
2 4
3 5
3 1 2
3 0 I
sacroiliac joints, the landmark being just medial to the
posterior superior iliac spines.
2) Pressure with the heel of the hand is applied
over the sacrum.
3) Pressure is applied with the thumb in the
midline at points between the spines of L4, L5, and S1.
Results. As Table 1 demonstrates, we have been
unable to show that any of these tests, as normally
performed, have any clinical value in helping to distin-
guish between ankylosing spondylitis and noninflam-
matory back disorders. We have deliberately separat-
ed a group of patients with back pain and morning
stiffness but with normal sacroiliac radiographs. We
believe that such patients-some of whom may have
Reiter’s syndrome or psoriasis-also have an inflam-
matory sacroiliac disease, but this remains controver-
sial. Contrary to previous suggestions, the tests as-
sessed do not appear to offer any diagnostic help in
this group either. The use of two tests in combination,
e.g., hip extension plus any other one, did not provide
an increase in diagnostic specificity.
Discussion. All the above tests (except number 3
described under “Direct pressure” in Patients and
Methods) have been recommended implicitly or ex-
plicitly in one or more standard works of rheumatol-
ogy. We believe that this may result from a “common
sense” approach that stressing the sacroiliac joint
ought to be positive in sacroiliac disease, plus perhaps
the reinforcement brought by finding occasional posi-
tive responses. Thus, a recent textbook on ankylosing
spondylitis states that “sacroiliac strain pain by what-
ever techniques elicited is worth testing for supporting
evidence . . . However it is a fickle sign” (9). Calin and
Fries (10) state that they have had “limited success in
trying to objectively detect disease at the sacroiliac
BRIEF REPORTS
joints on physical examination.” Our results would
support this and demonstrate that these tests, com-
monly thought to be helpful, are of no value in making
the distinction between ankylosing spondylitis and
other causes of chronic low back pain.
ACKNOWLEDGMENT
We are grateful to Dr. J. S. Percy for his review of
the manuscript.
REFERENCES
Thompson M: Discussion on the clinical and radiological
aspects of sacroiliac disease. Proc R SOCMed 50:847-
850, 1957
Newton DRL: Discussion on the clinical and radiologi-
cal aspects of sacroiliac disease. Proc R SOC Med
50:850-853, 1957
Moll JMH: Ankylosing spondylitis, Copeman’s Text-
book of the Rheumatic Diseases. Fifth edition. Edited
1577
by JT Scott. Edinborough, London, and New York,
Churchill-Livingston, 1978, pp 5 11-536
4. Polley HF, Hunder GG: Physical Examination of the
Joints. Second edition. Philadelphia, W.B. Sanders,
1978, p 175
5. Partridge KEH: Rheumatology and Immunology. First
edition. Edited by AS Cohen. New York Grune &
Stratton, 1979
6. Bluestone R: Arthritis and Allied Conditions. Ninth
edition. Edited by DJ McCarthy. Philadelphia, Lea &
Febiger, 1979, pp 620-632
7. Boyle JA, Buchanan WW: Clinical Rheumatology. First
edition. Blackwell, 1971
8. Calin A: Ankylosing spondylitis, Textbook of Rheuma-
tology. Edited by WN Kelley, ED Harris Jr, S Ruddy,
CB Sledge. Philadelphia, London. Toronto, W.B.
Saunders Company, 1981, pp 1017-1030
9. Dixon A St J , Macleod M: Diagnostic problems and
differentiated diagnosis, Ankylosing Spondylitis. First
edition. Edited by JMH Moll. Edinborough, London,
and New York Churchill Livingstone, 1980
10. Calin A, Fries JF: Ankylosing Spondylitis. Med Exam
Pub1 Co, 1978