Intertester Reliability for Selected Clinical Tests of the

Sacroiliac Joint

NANCY A. POTTER
and JULES M. ROTHSTEIN

The purpose of this study was to examine the intertester reliability of 13 tests for
sacroiliac joint (SIJ) dysfunction. Eight therapists examined 17 patients in two
clinical settings. In each case, two therapists independently examined the pa-
tients and obtained results on all 13 of the SIJ tests. Patients with lumbosacral
pain and unilateral lower extremity symptoms of a duration less than one year
were examined. All the therapists had specialized in orthopedic physical therapy
and had been trained in SIJ examination. Reliability was poor; 11 of the 13 tests
resulted in less than 70% agreement. The two tests that relied solely on subjective
patient response and imparted no information on SIJ position or mobility were
within a range of 70% to 90% agreement. Our findings suggest the necessity of
reviewing examination methods for the SIJ and improving reliability of clinical
testing of this joint.
Key Words: Physical therapy, Sacroiliac joint.

The sacroiliac joint (SIJ) has been
implicated as a source of pain by many
authors.1-4 Therefore, the SIJ is often
evaluated by clinicians who examine pa-
tients with lumbosacral pain. Assessing
SIJ dysfunction is important, and many
physical therapists evaluate this joint in
the course of their daily practice. Of the
numerous tests for the SIJ, 13 are most
often used by clinicians.1,2,4
Literature regarding the SIJ most
often focuses on joint structure and
deals with the question of whether mo-
tion actually exists at the SIJ. The irreg-
ular joint configuration and the ten-
dency to develop early osteoarthritic
changes at the SIJ have led some authors
to deny that motion usually occurs at
the joint.5-7 Clinicians now generally
agree, however, that a small but signifi-
cant amount of motion occurs at the
SIJ,8-12 although the arthrokinematics of
the joint remain controversial. Many
different descriptions of the SIJ motion
exist.1-4,8-12 Consequently, many differ-
Ms. Potter is Staff Physical Therapist, Profes-
sional Physical Therapy, Inc, St. Louis, MO 63141.
Address correspondence to 1371 Schulte Hill Dr,
Maryland Heights, MO 63043 (USA). This study
was completed in partial fulfillment of the require-
ments of her Master's of Health Science degree in
Physical Therapy at Washington University, St.
Louis, MO 63110.
Dr. Rothstein is Assistant Professor, Department
of Physical Therapy, Medical College of Virginia,
Virginia Commonwealth University, Richmond,
VA 23298.
This article was submitted August 3, 1984; was
with the authors for revision 23 weeks; and was
accepted May 10, 1985.
ent clinical tests are used to evaluate the
joint.1-4
The 13 most common tests were se-
lected for examination for reliability in
this study. Reliability, or reproducibil-
ity, is necessary for a test measure to
yield meaningful results. Without relia-
bility, a test may give illusory informa-
tion, although demonstrations of relia-
bility alone are insufficient to determine
if a test is valuable.7 Evaluation tech-
niques must yield reproducible findings,
that is, be reliable, if results are to be
meaningful. To avoid confusion and
discrepancies in testing methods, we
used standardized operational defini-
tions in our study. The purpose of this
study was to determine whether a group
of highly trained clinicians could repli-
cate each other's findings in tests of the
SIJ on patients with lumbosacral symp-
toms.
METHOD
Procedure
Our subjects were 17 patients referred
for physical therapy to either of two
physical therapy and sports medicine
outpatient clinics during a three-month
period. Patients with back pain repre-
sented a large percentage of the patients
treated in both clinics. The eight thera-
pists (five at clinic 1 and three at clinic
2) graduated from six different schools
and had from 2 to 18 years of clinical
experience (mean, 7.6 ± 4.5 years). All
therapists had previous experience in
general hospital care before specializing
in orthopedic therapy at the clinics. All
therapists had been required to attend
at least two continuing education classes
on advanced musculoskeletal evalua-
tion and manual therapy each year, and
six of the eight had attended courses on
the SIJ.
The subjects' chief complaint was uni-
lateral buttock pain with a duration of
not more than one year. The pain could
be associated with paralumbar pain or
pain into the posterolateral lower ex-
tremity as distal as the ankle, or with
paresthesia in the lower extremity. Pa-
tients with neurological involvement or
an acute lateral lumbar shift as described
by McKenzie13 were not accepted into
the study. The patients with shifts did
not have primary involvement of the
SIJ joint and were not accepted into the
study. Essentially, the only patients cho-
sen as subjects in this study were those
in whom SIJ testing would be conducted
routinely as part of their clinical evalu-
ation. Each subject was examined for
the study only when initially assessed at
the clinic.
Each therapist at the two clinics was
given a list of random pairings with a
second therapist at the same clinic. After
a subject was evaluated and the results
charted, the first therapist consulted the
list and asked the next listed therapist
(on random pairing sheet) to examine
the patient. The second therapist ex-
amined the patient and noted the find-
ings on a chart. The therapists did not

Volume 65 / Number 11, November 1985 1671

TABLE 1
Tests to Examine the Sacroiliac Joint and Possible Findingsa
Testb
1. Palpation in standing of
iliac crest levels
3. Palpation in standing of
PSIS levels
5. Palpation in standing of
ASIS levels
8. Standing flexion test
7. Standing Gillet test
2. Palpation in sitting of il-
iac crest levels
4. Palpation in sitting of
PSIS levels
6. Palpation in sitting of
ASIS levels
9. Sitting flexion test
10. Supine iliac gapping
test
12. Supine-long sitting
test
11. Side-lying iliac
compression test
13. Prone knee flexion test
a
Tests are listed in the order used during the clinical examination.
b
The numbers correspond to the order of the tests as they are described in the text.
discuss the patient with each other. Data
sheets were sealed in an envelope and
were not examined until after the study
was completed at both the clinics.
After 17 patients were examined by
two therapists (14 patients in clinic 1
and 3 patients in clinic 2), the sealed
envelopes were opened. The patients
were 10 men and 7 women, ranging in
age from 24 to 58 years. The mean age
was 39 years and the median was 36
years. The age range for the women was
33 to 45 years, ( , 39.6). The age range
for the men was 24 to 58 years ( ,38.7).
Referring diagnoses were typically
"lumbar strain," "lumbosacral strain,"
and "sacroiliac strain."
Tests
Thirteen SIJ tests were examined for
reliability (Tab. 1). These tests were per-
formed in an order dictated by patient
positioning because this is the usual se-
quence in clinical practice. Random test
order was not used in the study because
it is not traditionally used in clinical
practice and could have caused patient
inconvenience from the numerous
changes of position that would have
been required. Therefore, random order
would have introduced a source of error
to the measurement that would not be
relevant to clinical practice.
Description: The procedure is the same
as test 1, but the patient sits erect on a
flat surface (chair or elevated mat).
Possible Findings Possible findings: The same as test 1.
left high right high even 3. Name: Palpation in standing of pos-
terior superior iliac spine (PSIS) lev-
left high right high even els.2
Description: The patient stands with feet
left high right high even
approximately 12 in apart. The therapist
left high right high even
stands or squats behind the patient,
left high right high even places her thumbs below each PSIS, and
left high right high even pushes up so that each thumb rests
firmly beneath the bony point of the
left high right high even landmark.
Possible findings: The therapist notes
left high right high even the relationship of thumb heights to
each other, that is, are they even, or is
left high right high even one higher than the other?
pain left pain right no pain
4. Name: Palpation in sitting of PSIS
left short right short even levels.2
Description: The procedure is the same
pain left pain right no pain as test 3, but the patient sits erect on a
flat surface (chair or elevated mat).
left short right short even Possible findings: The same as test 3.
5. Name: Palpation in standing of an-
terior superior iliac spine (ASIS)
levels.2
Description: The patient stands with feet
Because different versions exist for approximately 12 in apart. The therapist
many of the SIJ tests, operational defi- stands or squats in front of the patient,
nitions for each test were written before places her thumbs on the patient's pelvis
collecting data. To ensure uniform test- below each ASIS, and pushes up so each
ing procedure, all the therapists partici- thumb rests directly beneath the bony
pating in the study reviewed these landmark. The therapist gently pushes
definitions and agreed that they were soft tissue away when palpating for the
appropriate. The definitions were cho- landmark.
sen because both the investigators and Possible findings: The therapist notes
the clinicians participating in this study the relationship of thumb heights to
thought they were clinically useful and each other, that is, are they even, or is
theoretically sound. one higher than the other?
Both examiners performed the tests 6. Name: Palpation in sitting of ASIS
in the same sequence, which was dic- levels.2
tated by practical considerations. The Description: The procedure is the same
testing order was as follows: 1, 3, 5, 8, as test 5, but the patient sits erect on a
7,2,4,6,9, 10, 12,11, 13. The following flat surface (chair or elevated mat).
operational definitions were used for the Possible findings: The same as test 5.
tests: 7. Name: Standing Gillet test (R. Er-
1. Name: Palpation in standing of iliac hard, PT, DC, personal communi-
crest levels.2 cation, 1981).
Description: The patient stands with feet Description: The patient stands with feet
12 in apart. The therapist stands or approximately 12 in apart. The therapist
squats behind the patient and places the stands behind the patient and places one
radial border of her hands at the pa- thumb directly under one PSIS and the
tient's waist. The therapist's hands then other thumb at the S2 tubercle (on the
move down on the iliac crests and gently sacrum at the level of the PSIS). The
push the soft tissue away. patient stands on one leg and flexes the
Possible findings: The therapist notes other hip and knee toward the chest.
whether hands (representing crest levels) The therapist palpates the PSIS on the
are level in relationship to one another side beingflexed.The test is repeated on
or one is higher than the other. the other side.
2. Name: Palpation in sitting of iliac Possible findings: As motion is com-
crest levels.2 pleted at the hip joint, the palpated PSIS

1672 PHYSICAL THERAPY


should dip downward. A positive test is
one in which this dip does not occur.
8. Name: Standing flexion test.2,4
Description: The patient stands with feet
approximately 12 in apart. The therapist
stands or squats behind the patient and
places her thumbs directly under each
PSIS. The patient bends forward as far
as possible while keeping the knees ex-
tended. The extent of cranial movement
of each PSIS is observed by the therapist.
Possible findings: Each PSIS should
move an equal amount in a superior
direction. A positive test is one in which
one PSIS moves further in a cranial
direction than the other. The side with
the greater movement is the side of the
articular restriction. Because contralat-
eral hamstring tightness, not SIJ dys-
function, could cause this finding, ham-
string tightness should be examined to
rule out any effect of tightness.
9. Name: Sitting flexion test.2,4
Description: The patient is seated side-
ways on a chair (so that the patient's
back is visible to the examiner). The
patient's feet are flat on the floor; the
knees are flexed to 90 degrees. The pa-
tient keeps his legs sufficiently apart to
allow the shoulders to come between
them when forward bending the spine.
The therapist kneels or squats behind
the patient and places a thumb directly
under each PSIS. The patient bends for-
ward as far as possible between his knees
and reaches his hands toward the floor.
Possible findings: Each PSIS should
move a slight but equal amount in a
cranial direction. A positive test is one
in which one PSIS moves more superi-
orly than the other. The side with greater
movement is the side of the articular
restriction.
10. Name: Supine iliac gapping test.6
Description: The patient lies supine
while the therapist places the heels of
her hands on the ASIS of the ilia and
presses downward and laterally. The
therapist's arms are crossed to increase
the lateral component of force applied
to strain the sacroiliac ligaments. Exces-
sive motion of the pelvis is avoided to
minimize movement of the lumbar
spine. If the patient describes lumbar
pain during the test, then a support is
placed at the low back to rule out lum-
bar involvement, and the test is re-
peated.
Possible findings: A positive test is one
in which the patient complains of the
reproduction of pain in the gluteal or
Volume 65 / Number 11, November 1985
posterior crural areas when the test pres-
sure is applied.
11. Name: Side-lying iliac compression
test.6
Description: The patient lies on his side.
The therapist stands above the patient
with her elbows locked in extension and
her palms interlocked over the upper-
most margin of the iliac crest. The ther-
apist exerts downward pressure on the
iliac crest with the pressure well forward
on the bone.
Possible findings: A positive test is one
in which the sacroiliac pain, gluteal
pain, or posterior crural pain is repro-
duced by the downward pressure.
12. Name: Supine—long sitting test.2,4
Description: The patient lies supine
while the therapist places her thumbs on
the inferior borders of the medial mal-
leoli to outline the position of the mal-
leoli. The two malleoli are approxi-
mated to facilitate comparisons of their
positions. The patient then sits up; he
can use his hands if necessary but must
push evenly with each hand to avoid
shifting the pelvis.
Possible findings: The therapist notes
any change in relationship of the mal-
leoli. One leg appearing to lengthen in
relationship to the other when the pa-
tient moves from supine to sitting indi-
cates posterior innominate rotation on
that side. Conversely, one leg appearing
to shorten in relationship to the other
indicates an anterior innominate rota-
tion on that side. One leg remaining
consistently shorter or longer in rela-
tionship to the other indicates an ana-
tomical leg-length difference.
13. Name: Prone knee flexion test.2,4
Description: The patient lies prone and
preferably wears shoes. The cervical
spine is in a neutral rotation position,
and the arms rest comfortably at the
patient's sides. The therapist stands at
the end of the table and grasps the pa-
tient's feet so that the therapist's thumbs
pass transversely anterior to the heel of
the shoe (or along the distal end of the
calcaneus if the patient is without
shoes). The therapist maintains the in-
dex fingers just posterior to the lateral
malleoli and distal fibular shafts and
holds the feet in the same degree of
pronation-supination and slight external
rotation. The feet are placed next to each
other. The therapist notes the apparent
leg length by observing the position of
the heels in relationship to each other.
The therapist then passively flexes the
patient's knees to 90 degrees.
RESEARCH
Possible findings: The therapist notes
any change in the relationship of the
heel positions to each other as the pa-
tient's knees are passively flexed. In the
initial approximation of the feet, the leg
that appears shorter in relationship to
the other is considered to be on the side
of dysfunction. An apparent increase in
this leg's length so that it becomes the
longer of the two as the test is performed
indicates a posterior innominate rota-
tion on that side. If this leg remains
apparently shorter or becomes even
shorter in relationship to the other leg,
that side has an anterior innominate
rotation.
Data Analysis
Findings for each patient were first
analyzed by determining if the two ther-
apists agreed or disagreed on each of the
results. Each test had 17 total statements
about agreement and disagreement be-
cause 17 patients were in the study. Be-
fore the study began, we had decided
that a 70% agreement level would be a
minimum criterion for any test to be
considered reliable for clinical use.
Agreement at the 90% level was also
examined. A chi-square goodness-of-fit
test was applied to determine whether
90% and 70% levels of agreement had
been achieved for each clinical test.
RESULTS
Results showed intertester reliability
was generally poor for all tests except
the iliac gapping and compression tests,
which achieved about 90% and 70%
agreement, respectively (Tab. 2). None
of the other tests exhibited more than
50% agreement, and one test showed
only 23% agreement.
DISCUSSION
Interestingly, the iliac gapping and
compression tests were the only two tests
examined that relied solely on the pa-
tient's response to the therapist's action.
When the therapist performed the test,
the patient stated whether pain oc-
curred. Sacroiliac joint position and mo-
bility cannot be ascertained with these
two tests.
All other tests exhibited low reliabil-
ity, that is, 50% agreement or less. From
records obtained at the time of the
study, we examined whether the num-
ber of years of clinical experience of the
individual therapist and therapist pairs
1673
TABLE 2
Intertester Reliability for 13 Tests of Sacroiliac Joint Function

x 2 Value for Goodness x 2 Value for Goodness

Agreement
Test Number of Patientsa of Fit with 90% of Fit with 70%
(%) Agreement Expected Agreement Expected
1. Palpation in standing 17 35.29 329.52 55.73
of iliac crest levels
2. Palpation in sitting of 17 41.18 259.42 38.19
iliac crest levels
3. Palpation in standing 17 35.29 329.52 55.73
of PSIS levels
4. Palpation in sitting of 17 35.29 329.52 55.73
PSIS levels
5. Palpation in standing 16 37.50 300.44 48.76
of ASIS levels
6. Palpation in sitting of 16 43.75 232.56 31.57
ASIS levels
7. Standing Gillet test 15 46.67 203.82 24.82
8. Standing flexion test 16 43.75 232.56 31.57
9. Sitting flexion test 16 50.00 173.36 18.11
10. Supine iliac gapping 17 94.12 1.46b 26.57
11. Side-lying iliac 17 76.47 18.86 1.19b
compression test
12. Supine — long sit- 15 40.00 272.25 41.44
ting test
13. Prone knee flexion 17 23.53 48.36 100.63
test
a
N varies from 15 to 17 because of therapist recording omissions and errors.
b
These values are not significant with df = 1, p < .05 (the critical value of x 2 is 3.84).

TABLE 3
apist examined him. Treatment goals
Agreement Level of Therapist Pairs and Years of Experience
and the techniques used by the two ther-
apists c6uld even be diametrically op-
Therapist Pair Years of Experience Percentage Agreementa posed based on contrasting assessment
1-2 7-7 38.46 findings. Continuity of care would be
2-3 7-6 30.77 jeopardized if a different therapist had
4-5 2-4 46.15 to treat a patient, a situation that often
4-8 2-7 38.46 occurs in many clinics.
4-7 2-10 44.74 This study was conducted in two re-
4-1 2-7 38.46 lated outpatient clinics. The tests ex-
5-1 4-7 46.15
5-7
amined in this study are commonly per-
4-10 65.38
6-7 18-10 38.46
formed at the clinics. Therapists at both
6-4 18-2 38.46 clinics had extensive orthopedic experi-
8-6 7-18 53.85 ence and training in the area of back
8-7 7-10 57.14 care and SIJ. Although these tests are
8-5 7-4 38.46 used by many physical therapists, the
a results of this study cannot be general-
The percentage agreement refers to the average agreement for all 13 tests combined.
ized to all physical therapy settings.
Therapists in other clinical settings need
to examine reliability of these tests in
affected reliability. Examination of the standing and sitting positions) ranged their clinics.
data showed that agreement did not ap- from 35.3% to 43.8% (Tab. 1). Reliabil- Clinical palpation skills and testing
pear to relate to the years of experience ity of the Gillet test, standing and sitting methods for the SIJ should be reexam-
of the therapists. Agreement among flexion tests, supine-long sitting test, ined critically to ascertain why reliability
therapist pairs ranged from a low of and prone knee flexion tests were simi- is lacking. This reexamination is espe-
about 30% to a high of about 65%; the larly poor. The agreement level of 23.5% cially important in view of the training
majority of pairs were below 50% agree- for the prone knee flexion test was no- and expertise of the therapists who par-
ment (Tab. 3). Experience, or the lack table in that agreement approached ticipated in this study. The clinics used
of it, did not appear to affect reliability. what would be expected by chance. in this study were chosen because we
Palpation and observation of bony The variability between therapists in thought that reliability could be ex-
landmarks is a basic skill in physical test results is clinically important be- pected to be optimal in these settings,
therapy, yet agreement for the determi- cause treatment plans for a patient given the therapists' training and the
nation of pelvic landmark levels (in would differ depending on which ther- types of patients treated in the clinics.

1674 PHYSICAL THERAPY


Reliability may have been poor be-
cause of the therapists' inability to pal-
pate landmarks. The design of the study
did not take this factor into account.
Although we were unable statistically to
analyze the question, our examination
of the data suggested that patient body
type (ie, whether the subjects were lean
or obese) did not seem to affect the two
therapists' agreement.
Further clinical study is necessary,
and perhaps new tests or new opera-
tional definitions need to be developed
before the use of these SIJ tests can be
justified. The phenomena the tests as-
sume to measure, however, may not be
measurable but inherently labile, or pos-
sibly the movement assumed to occur
at the SIJ may not be measurable with
the types of tests currently in clinical
use.
CONCLUSION
The reliability of 13 selected tests of
SIJ function demonstrated that interra-
ter agreement for trained therapists was
less than 70% for 11 of 13 tests. The
two tests with values at or above 70%
imparted no information about joint
Volume 65 / Number 11, November 1985
position or mobility and relied solely on
the patient's subjective response. Con-
tinuity of patient care and repeatedly
effective treatment regimens for SIJ dys-
function are unlikely unless evaluation
techniques are reliable. Further study is
necessary to examine critically how the
SIJ can be reliably evaluated clinically.
Therapists using these tests should be
aware that, at least under the conditions
of this study, the tests were unreliable.
Acknowledgments. We thank Rich-
ard Erhard, PT, DC, for his assistance
in defining and imparting understand-
ing of the SIJ tests. We also express our
appreciation to Al Amato, PT, for his
encouragement and his willingness to
allow the use of the two clinics, Ballas
Physical Therapy and Sports Medicine
Clinic and Clayton Physical Therapy
and Sports Medicine Clinic, and to all
the therapists at both clinics who partic-
ipated in this study.
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