Peter A. Huijbregts, PT, DPT, OCS, FAAOMPT, FCAMT
As also noted by Dr. Laslett there is an overabundance of book and journal article references out there that provide models for diagnosis and management of sacroiliac joint dysfunction (SIJD) based solely on authority-based knowledge and—in my opinion—unwarranted extrapolations from anecdotal clinical observations and from basic science studies on lumbosacral region anatomy and (patho) biomechanics. When I was first introduced to Dr. Laslett’s work on reliability of individual sacroiliac joint pain provocation tests1, I have to admit that I was elated and at the same time confused.
Identifying myself strongly as a physical therapist specializing in orthopaedic manual physical therapy (OMPT), SIJD for me was a very real construct. I had spent many years perfecting means both to diagnose this dysfunction with manual diagnostic tests and to treat it with specific manipulative interventions and exercise instruction. However, time and again the positional and motion palpation tests required for establishing a specific OMPT diagnosis of a positional fault and/or direction of hypomobility that then could guide those favored manipulative interventions were shown to have insufficient reliability for clinical use. I was also well aware that these studies showing insufficient reliability questioned the very validity of the SIJD construct2. So finally, Laslett and Williams1 had established that four provocation tests had sufficient interrater reliability, whereas two other tests were noted to be potentially reliable.
Confusion set in for me after this initial elation when I realized that my clinical construct of SIJD, defined by Paris3 as a state of altered mechanics, characterized by an increase or decrease from the expected normal or by the presence of an aberrant motion, was in fact quite different from a diagnosis of sacroiliac joint pain. At that time—and still to some extent—my clinical reasoning was guided by a mechanism-based classification system that was founded on the premise that impairments identified during examination were the cause of musculoskeletal pain and dysfunction4. So now I was able to diagnose pain emanating from the sacroiliac joint but I was no closer to an evidence base for a diagnosis of SIJD that could then guide my specific OMPT interventions.