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Manual Therapy 10 (2005) 207–218 www.elsevier.com/locate/math Original article

Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests
Mark Lasletta,Ã, Charles N. Aprillb, Barry McDonaldc, Sharon B. Youngd a Department of Health and Society, Linko¨pings Universitet, Linko¨ping, Sweden b Magnolia Diagnostics, New Orleans, LA, USA c Massey University, Institute of Information and Mathematical Sciences, Albany, New Zealand d Mobile Spine and Rehabilitation Center, Mobile, AL, USA
Received 11 December 2002; received in revised form 1 September 2004; accepted 4 January 2005

Abstract
Previous research indicates that physical examination cannot diagnose sacroiliac joint (SIJ) pathology. Earlier studies have not reported sensitivities and specificities of composites of provocation tests known to have acceptable inter-examiner reliability. This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations, in relation to an accepted criterion standard. In a blinded criterion-related validity design, 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ. The tests were evaluated singly and in various combinations (composites) for diagnostic power. All patients with a positive response to diagnostic injection reported pain with at least one SIJ test. Sensitivity and specificity for three or more of six positive SIJ tests were 94% and 78%, respectively. Receiver operator characteristic curves and areas under the curve were constructed for various composites. The greatest area under the curve for any two of the best four tests was 0.842. In conclusion, composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ. Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections. When all six provocation tests do not provoke familiar pain, the SIJ can be ruled out as a source of current LBP. r 2005 Elsevier Ltd. All rights reserved.
Keywords: Sacroiliac joint; Low back pain; Physical examination; Diagnosis; Validity; Sensitivity; Specificity

1. Introduction
The sacroiliac joint (SIJ) can be a nociceptive source of low back pain (Fortin et al., 1994a, b; Bogduk, 1995).
SIJ pain has no special distribution or features and is similar to symptoms arising from other lumbosacral structures. There are no provoking or relieving movements or positions that are unique or especially common to SIJ pain (Dreyfuss et al., 1996; Fortin et al., 1994a, b;
Schwarzer et al., 1995; Maigne et al., 1996; Fortin and
Falco, 1997). The clinical diagnosis of symptomatic SIJ
ÃCorresponding author. Department of Health and Society,
Linkopings University, Auckland, New Zealand. Tel.: +64 9 626 0015.
E-mail address: mark.laslett@xtra.co.nz (M. Laslett).

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.01.003 remains problematical, but the ability to make the diagnosis is an important objective. It may be presumed that treatment strategies for SIJ lesions should differ from strategies intended to relieve and treat pathologies of other structures such as disk, nerve root or facet joint pain. Without a readily accessible means of differentiating between these possible sources of pain, treatment strategies are perforce non-specific, and likely to have at best, modest efficacy.
At present, a current acceptable method of confirming or excluding the diagnosis of a symptomatic SIJ is fluoroscopically guided, contrast enhanced intra-articular anaesthetic block (Fortin et al., 1994b; Grieve, 1988;
Merskey and Bogduk, 1994; Schwarzer et al., 1995;
Sakamoto et al., 2001; Adams et al., 2002). While

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certain SIJ tests have been shown to have