Abstract
BACKGROUND:
Low back pain is a common clinical complaint for young athletes. Making the diagnosis of sacroiliac (SI) pain is often challenging, as the clinical diagnosis is challenging with many non-specific physical examination findings. Previous research has attempted to identify the most accurate physical examination tests; however, the findings were limited in adult populations [1]. The most accurate physical examination test has not been established in pediatric, adolescent, and young adult patients with SI pain. Therefore, the purpose of this study was to identify the sensitivity and specificity of SI physical examination tests in order to diagnose more accurately SI joint pathology in pediatric, adolescent, young adult athletes.
METHODS:
A prospective study design was used. Pediatric, adolescent, and young adults presenting to the Sports Medicine clinic with low back pain underwent a series of physical examination tests for SI pathology. The physical examination tests for SI included: 1) pelvic distraction, 2) thigh thrust, 3) figure of four, 4) flexion-abduction-external rotation (FABER), 5) pelvic compression, 6) sacral torque, 7) sacral compression, 8) Gaenslen’s test, and 9) Stinchfield’s test. All study patients self-reported pain levels on a Visual Analog Scale (VAS) from 0 to 100 following each test. All study patients were then treated with, an ultrasound-guided injection of anesthetic and corticosteroid into the SI joint.
To evaluate accuracy of each of the 9 provocation tests, two by two (2 x 2) contingency tables were developed by positive (+) or negative (-) response to SI special provocation test prior to SI injection and (+) or (-) response to anesthetic and corticosteroid following SI injection. Those who demonstrated 50% or greater pain alleviation immediately following injection were diagnosed with an SI pathology, and thus a (+) response. Based on the 2 x 2 contingency tables, sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratio, and accuracy of each provocation test were calculated.
RESULTS:
A total of 69 participants (age: 19.5 ± 5.5 years old, age range: 13 - 52, sex: 11 males and 58 females) were tested. There were 14 participants who had complaints of bilateral SI symptoms. Thus, right and left sides were treated separately, which resulted in a total of 83 data points. Table 1 summarizes the outcomes of each provocation test. The sacral torque maneuver was found to be the most sensitive (92.3%) and the most accurate (74.4%) in terms of diagnosing SI joint pathology. All maneuvers besides the Gaenslen test had over 50% sensitivity. However, accuracy of the distraction, Gaenslen, and Stinchfield maneuvers were under 50%.
CONCLUSION/SIGNIFICANCE:
In the pediatric, adolescent, and young adult populations, the leading three most sensitive clinical provocation tests for reproducing sacroiliac pain were the sacral torque, thigh thrust, and sacral compression tests. These three tests also demonstrate relatively high accuracy (>60%). These findings support the clinical utility of selected physical examination tests for accurately diagnosing SI joint pathology. Due to the relatively high number of false positives and false negatives, it is clear that more research are warranted to optimize these maneuvers before they can be considered as a standalone clinical tool. However, the implications of these results are encouraging and justify exploring the utility of provocative maneuvers of the SI joint in greater detail.
Statistics detailing the predictive power of the nine provocative maneuvers on SI joint pathology.
| Maneuver | Sensitivity (%) | Specificity (%) | Positive Predictive Value (%) | Negative Predictive Value (%) | Positive Likelihood Ratio | Negative Likelihood Ratio | Accuracy (%) |
|---|---|---|---|---|---|---|---|
|
|
53.8 | 18.8 | 72.9 | 9.1 | 0.66 | 2.46 | 46.9 |
|
|
84.8 | 5.9 | 77.8 | 9.1 | 0.90 | 2.58 | 68.7 |
|
|
60.0 | 11.8 | 72.2 | 7.1 | 0.68 | 3.40 | 50.0 |
|
|
70.8 | 11.8 | 75.4 | 9.5 | 0..80 | 2.48 | 58.5 |
|
|
60.0 | 17.6 | 73.6 | 10.3 | 0.73 | 2.27 | 51.2 |
|
|
92.3 | 5.9 | 78.9 | 16.7 | 0.98 | 131 | 74.4 |
|
|
80.0 | 5.9 | 76.5 | 7.1 | 0.85 | 3.40 | 64.6 |
|
|
42.9 | 35.3 | 71.1 | 14.3 | 0.66 | 1.62 | 41.3 |
|
|
54.8 | 12.5 | 70.8 | 6.7 | 0.63 | 3.61 | 46.2 |