1. Differential Diagnosis between
Lumbar and SIJ Generated Pain
Case Study
 CJ
o 30 yo F
o C/o sharpLBP for approx. 2 weeks
o Runner
o No children,nospecificonset
o You notice thatshe gesturestoher painbeingright-sidedwhenshe describesittoyou
o Sometimeshaspaindownherrightleg tothe knee andaroundinher groin(Dutton)
o Aggravatingfactors
 Rollingoverinbed
 Sit-to-stands
 Sitting/standingforlongperiodsof time
o Relievingfactors
 Lyingdownsupine/hook-lying
o Is currentlyaPT student,so she sitsall of the time!
 ReviewTreatmentBasedClassificationSystemforLumbarSpine (Fritzetal)
o ManipulationGroup
 Hypomobilitywithspringtesting
 FABQ<19
 Hip IR >35˚
o StabilizationGroup
 Hypermobilitywithspringtesting
 Increasingepisodefrequency
 3+ priorepisodes
o SpecificExercise Group
 Directional preference forextension/flexion
 Centralization
 Peripheralizationinopposite direction
o Traction Group
 Peripheralizationwithoutabilitytocentralize atall
o Funfact! JohnChilds,co-authorof the TreatmentBasedClassificationSystem, believes
that people donotnecessarilyfall intothesecategories. He alsobelievesthatthe SIJ
doesnotmove.
Nowwhat??? Screening!
 Observationandpalpation –Standing
o No specificasymmetriesfound
 No specificrelationshipbetweenLBPsymptomsandSIJinnominate asymmetry
(Huijbregts referringtoLevangie etal study)

2.  CommonCompensatoryPattern(PopereferringtoJGordon Zink’sproposition)
 Due to positionsinthe wombandcumulative posture,developcommon
compensatorypattern
o She isable to pointdirectlytoherright PSISas the mostaggravatingpointof herpain
(Fortin)
 What are we immediatelythinking??? SIJ
 Gillet’shypomobilitytest –specificityof 97%,butsensitivityof 12% (Levangie)
o Innominatesappeartomove appropriatelyinstanding
o Gillet’sisnota testfor asymmetry!(Levangie)
 ROM – standing
o Repeated movements –flexion,extension,side-bend,rotation
 Still sharp,localizedRPSISpain
 Some paindownR legto knee
 No centralization/peripheralization/changeinsymptoms
 Laslettetal
 ShowedthatMcKenzie methodcouldbe usedtorule in/outdiscogenic
painwhenevaluatingforSIJgeneratedpain(Laslettetal)
 Reference standardforSIJinvolvement –fluoroscopicallyguided
injection
 Participantsall participantsreceivedinjection
o All whotestedpositive fordiscogenicinvolvementviaMcKenzie
methodwere negativeforSIJinvolvementviainjection
o WHAT IF!!! What if she had hadpainwithall movements,butwe were 95% sure it was
SIJ???
 Accordingto Laslettetal (Dx/Validity),if there ispainprovocationwithall ROM
tests,SIJprovocationtestswill all be positive,butwe cannotrule themin.
 ROM/MMT – globally4+/5 bilaterally
o R groinpain withresistedR/Lhipflexion
o R hipIR limitedmore thanL hipIR ROM(Dutton,referringtoCibulkaetal study)
 Icingon the cake! PainprovocationtestsforSIJinvolvement
o Must have a clusterof 2-3 positive teststorule inSIJ,manyfalse-positives(Laslett)
o In orderof importance (Laslettetal Dx/validity):
 Thighthrust test– positive
 Distractiontest– positive
 Compressiontest
 Sacral thrusttest
 ***Can include Gaenslen’stest,but2/4 previouspositive testshasnearlyas
highof a likelihoodratioas3/6 testincludingGaenslen’s
Yay! It’s SIJ!!! Nowwhat???
 Form vs.Force Closure (Pool-Goudzwaard)
o Form closure – the shape of the jointandthe alignmentof the innominateskeeps
everythingtogether

3. o Force closure – the fascia,muscles,andligamentsholdthe jointstogether. Thisallows
for some movement(ifyou’re the type whobelievesthe jointmoves;otherwise we’re
justtellingareallygoodstoryto our patients,whichcanbe justas important,butI
digress)
o Test– ASLR
 If CJ requiresverbal cueingforabdominalbracingin ordertoperforman ASLR,it
ispoor force closure
 If CJ is still unable toperformanASLRwithpropermuscle recruitmentbutcan
do itwitheitheranSI beltor manual pelvicstabilization,she haspoorform
closure
 Provide anSI belttoher if she has poorform closure!
 Treatment
o General consensusislumbopelvicstabilizationtherapeuticexercise (Laslett)
o Pool-Goudzwaardetal’ssystem:
 Phase 1: isometriccontractionof transverse abdominisandmultifidus
 Phase 2: contractionof transverse abdominis andmultifiduswithactive LE
movement
 Phase 3: activatingtransverse abdominisandmultifidusduringtrunk
movement
 Lastly(notlistedasPhase 4, but probablyshouldbe),afterproperrecruitment
of transverse abdominisandmultifiduswithmovementisachieved,workon
strengtheningothercore muscles,suchasglutes,obliques,andlatissimusdorsi.
Thisshouldnotbe done earlierinordertopreventexcessivesheeringforceson
the SIJ
Congratulations!!! After4-6weeks,CJisfeelingamazinglybetter,andshe hasbeenable toditchthe SI
belt! She’sbackto running, andsittinginclassis still awful,butatleastit’snota painin the butt!