Institute for sacroiliac treatment, research, and education
  • Home
  • About Us/Contact Us
    • Our Method
    • Qualifications
    • Testimonials >
      • Physical Therapists Feedback
      • Massage and Bodywork Therapists
      • Rolfers Feedback
      • Workshops Feedback
      • Distance Learning
    • Lectures & Presentations
    • Contact Us
  • Patient Info
    • Hesch Certified Sacroiliac Practitioners
    • New Patient's FAQ's
    • Local Aurora, Denver, and Colorado Area New Patient Info
    • Out-of-State New Patient Info
    • Chart Review, Phone or Zoom Consultation
    • Patient/Client Feedback
  • Research & Publication
    • Hesch Method Basics
    • Manual Therapy >
      • Regional Interdependence
      • Righting Reflex
      • Hypomobility & Hypermobility
      • Pelvis: Cervical Compensation
    • Professional Library >
      • Complex Pelvic Dysfunction
      • Cuboid Syndrome
      • Coccyx
      • Foot, Ankle, Knee, Hip
      • Inguinal Canal
      • Low Back Pain
      • Pregnancy & SIJ
      • Shoulder
      • Sacroiliac & Pelvis
      • SIJ Miscellaneous
      • Thoracic Spine & Ribcage
      • TMJ & Cervical Spine
    • Hesch Publications
  • Education
    • Online Sacroiliac Certification $199.00
    • Online Cervical Certification $199.00
    • New York, NY - March 25, March 26, 2023
    • Information on Workshop
    • Whole Body Course $349.00
  • Store
​

Evaluating Sacroiliac Joint Play With Spring Tests

Letter to the Editor of J OB/GYN PT

Feature 
Elaine Pomerantz, MS, Editor
Evaluating Sacroiliac Joint Play with Spring Tests

by Jerry Hesch, PT

The sacroiliac joint (SIJ) has been implicated as a source of low back pain (LBP) by many clinicians and researchers including Greenman (1995), Lee (1989, 1992, 1996), and Vleeming, et al (1992). There is an increasing interdisciplinary interest in the role of the SIJ and LBP (Vleeming, et al 1992, 1995). The "Se­cond Interdisciplinary World Congress on Low Back Pain: The Integrated Function of the Lumbar Spine and Sacroiliac Joint" was held on November 9-11, 1995 in San Diego, California. The Congress proceed­ings total 860 pages. In 1994, the Canadian Athlet­ic Therapist National Conference was dedicated entirely to the SIJ. There is ample evidence that many disciplines are experiencing strong interest in the role of the SIJ and LBP. While there is a considerable body of literature regarding the SIJ, there is also consider-able debate regarding this complex articulation, its role in LBP, and the value of its clinical evaluation and treatment. During the peripartum state, it is certain­ly relevant to evaluate and treat the SIJ. However, the consideration of the SIJ should not be limited to the childbearing years; women can suffer lumbopelvic pain and biomechanical dysfunction during any life stage. The purpose of this article is to present infor­mation on the SIJ, and introduce joint spring tests to qualitatively evaluate motion.

The SIJ may cause pain due to disease, inflamma­tion, or movement dysfunction. However the pain model can be limiting as biomechanical dysfunction of the SIJ and pelvis is commonly present in the ab­sence of pain (Hesch 1996). The important relation-ship of the SIJ and pelvis to the rest of the musculoskeletal system should not be ignored in the absence of pain.

The SIJ may cause pain due to
disease, inflammation, or movement
dysfunction.


Movement dysfunction may exist as hypermobili­ty or as hypomobility. The normal SIJ functions as a tri-plane shock absorber which transfers upper body weight into the pelvis and lower extremities and as­sists absorption of the force of heel strike (Porterfield & DeRosa 1991). If the SIJ is hypomobile or hyper-mobile it cannot effectively dissipate stress from ac­tivities of daily living. Confusion exists as to how hypermobility and hypomobility are defined. True hypermobility can be hereditary or traumatic. It can occur with pregnancy in response to the hormonal changes and mechanical trauma of altered posture, weight gain, and delivery (Mens, 19911. True hypomo­bility can exist in the elderly due to degenerative changes and in disease processes such as early stages of Reiter's disease or ankylosing spondylitis; complete fusion can occur in later stages. Apparent hypermobility and apparent hypomobility are muta­ble properties of dysfunction which respond readily to treatment (Hesch 1996).

Apparent hypermobility and apparent hypomobili­ty often co-exist. Spring testing of the pelvis reveals one or several direction(s) of decreased mobility, whereas testing in the opposite direction(s) reveals increased mobility. This is quite common, and treat­ment directed at restoring normal movement in the direction of hypomobility usually restores normal movement in the direction of the apparent hypermo­bility as well.

SIJ dysfunction during pregnancy is not limited to true hypermobility. Macro or micro trauma, activities of daily living or "creep" (defined by Greenman as a decrease in tissue resistance to a load because of previous load application) may create a fixation and apparent hypomobility with a background of true hypermobility. The former can be more symptomat­ic and after reducing the acute strain pattern the background hypermobility can be managed more readily.

The SIJ has a small amount of functional motion as does the symphysis pubis (Vleeming, et al 1992). Bernard (1992) has demonstrated through fluorosco­py that the SIJ moves with manually applied loads such as those that are utilized in evaluation and treat­ment. Brooks et al used realtime sonograms to demonstrate movement in vivo with spring tests (1995). Physical therapists recently demonstrated the predictive value of a SIJ evaluation regarding insta­bility (Graham-Smith, et al 1996). The physical ther­apy evaluation indicated suspected SIJ instability. This was validated when a tear in the anterior cap­sule was discovered with dye injection into the SIJ under fluoroscopy. What has not been established is whether or not manual clinical tests and treatments specifically affect only the SIJ. It may be that mobil­ity is evaluated and treated manually as part of the integrated system of the spine, pelvis, and hip. The SIJ is part of this system, and it does not function in an isolated fashion. Mobility tests that attempt to

 isolate actual joint play may yield useful information about the system, however, we cannot say with cer­tainty that mobility tests exclusively isolate only the SIJ. The SIJ is unique in that it is surrounded by some of the largest and most powerful muscles of the body, and many have part of their origins or insertions on ligaments or capsule of the SIJ. Muscle tension in-deed can decrease SIJ mobility, as has been demon­strated by Vleeming, et al (1989).

Mobility tests that attempt to isolate
actual joint play may yield useful
information about the system, however,
we cannot say with certainty that
mobility tests exclusively isolate
only the SIJ.


SIJ spring tests may indicate perceived motion that may be greater than the actual movement occurring within the SIJ. As bony landmarks used are at a dis­tance to the joint, they can amplify the perception of motion. The spring test may be applied in one plane and yet may produce tri-plane motion in the joint. A spring test may induce motion at both SIJ's and the symphysis pubis in spite of our efforts at isolation. Spring testing might induce a small degree of car­tilage and bone deformation. Lastly, in spite of our best efforts to isolate only the SIJ, the entire lumbopelvic-hip region might participate to some degree. These reasons do not detract from the clini­cal utility of the spring tests, as they evaluate an im­portant and often overlooked aspect of joint function which is joint play.

Mobility tests can be general or specific. Palpating pelvic bony landmarks during trunk or hip flexion is a general mobility test as many joints and many mus­cles come into play. In contrast, a posterior rotation-al force applied tc the anterior superior iliac spine in supine is a spring test that evaluates joint play. Bark, et al (1990) defined joint play as the motion that oc­curs within the joint as a response to an outside force but not as a result of voluntary movement. General and specific mobility tests are important in evaluat­ing clients with suspected SIJ dysfunction. The spring tests give more specific information about joint and ligament function and integrity. The general mo­bility tests will give more information about whole patterns of motion influenced by several joints and several muscle groups. The following general mobil­ity tests are presented in the literature and are in fairly common use: long sit test, standing hip flexion (Gillet) test, standing trunk flexion test, sitting flexion test (Potter & Rothstein 1985). These gross motion tests implicate faulty motion of the pelvis as a unit but are not very specific, vet are often utilized to evaluate purported faulty "SIJ motion." The SIJ is within the pel­vis and a more appropriate description might be "faulty Jumbo-pelvic-hip" motion. The spring tests and gross motion tests evaluate very different emer­gent properties of the SIJ and pelvis. The gross mo­tion tests cannot be performed in prone and supine and the spring tests cannot be performed in sitting or standing. The use of the term spring seems very appropriate when testing the quality of pelvic joint play as there is a very discernable elastic feel in load­ing the pelvic joints, imparting the actual spring test, and in the quality of recoil. This elastic property is distinctly different from other joints in the body.

Walker (1992) asks a relevant question with regard to motion testing:

"Is the motion present adequate in total range to be detected by observation and manual palpation, as extensively described by several clinicians? ...The minimal range of motion present in probably most of the population casts doubt on whether therapists can detect 1 to 3 degrees or 1 to 3 mm of motion occurring specifically at the SIJ. Perhaps the term play (joint play) should be used whet. Referring to the SIJ, as motion implies quantity of motion similar to other synovial joints, which does not appear to be the case." pp. 911, 913

The SIJ does not exist in isolation with regard to anatomy and function. Perhaps more important thanthe fact that motion occurs within the SIJ, is the con­cept that it occurs through the SIJ. Proper function of the pelvic articulations requires the ability to trans-late forces through these articulations and to dissi­pate intrinsic and extrinsic forces.

Spring tests are performed on both sides of the pel­vis. As movement dysfunction can exist within a sym­metrical pelvis they are always utilized as a general screening tool. The clinician applies firm and continu­ous pressure to the bony landmark until motion no longer occurs. At this point the soft tissue slack is taken up. The actual spring test is then performed when an additional force is imparted. When perform­ing the spring test, it is important to note the quality of the initial load, the endfeel, the quality of recoil, as well as the client's subjective response. Retest if unsure. Do not abruptly let go but rather allow the recoil to return to the point where the slack is taken up. The quality of joint play is rated as normal, hypomobile or hypermobile. A zero to six scale can also be utilized:

0 = Ankylosis or no detectable movement

1 = Considerable limitation in movement

2 = Slight limitation in movement

3 = Normal (that is for the individual)

4 = Slight increase in motion

5 = Considerable increase in motion

6 = Unstable (Paris 19911.

Of course there is a degree of subjectivity in
 rating the joint play. Skill in joint spring testing comes with practice and training. The primary intent of the spring tests is not to reproduce and isolate pain, but rather to qualitatively assess joint play. It is not un­common for clients to have biomechanical dysfunc­tion that is sub-threshold, and therefore pain is not provoked with spring testing. If pain does occur with spring testing, it is important to modify technique and attempt interpretation.

Spring tests can be measured with force trans­ducers e.g., MICROFET* muscle testing device. It is a hand held instrument that measures the amount of force applied by the clinician. After taking up the slack in the joint the clinician can then apply an ad­ditional force and determine how much force is ap­plied when joint play is perceived. Both sides are

When performing the spring test, it is
important to note the quality of the
initial load, the end feel, the quality
of recoil, as well as the client's
subjective response.


compared. The clinician can measure pre-treatment and post-treatment force. Most force transducers used in the clinic describe force in pounds (Ibs) or kilograms, though force described in newtons ac-counts for the influence of gravity. The spring tests average 20 lbs for taking up the slack and up to 40 Ibs to apply the spring test. The force needed may vary from person to person. The above averages serve as a guideline with which to develop the skill of ap­plying the spring test. However, the appropriate amount of force is the least amount that provides use­ful information without provoking pain. The initial load takes from 2-3 seconds and the spring test takes 1-2 seconds as does assessing the recoil.

A study was performed to determine whether ther­apists could learn to accurately produce specific forces to the lumbar spine (Keating, et al 1993). Ther­apists practiced applying specific forces by pushing on a bathroom scale. They then attempted to apply specific forces on the participant's lumbar spine (prone lying). The practitioner stood on a force plat-form while they imparted the force. The reduction in weight measured by the force platform equalled the force applied to the lumbar spine. The authors con­cluded that therapists can learn to quantify applied forces and that a bathroom scale, (non-digital) can be an adequate learning tool.

Joint play tests are part of a standard orthopedic physical therapy evaluation of synovial joints of the body (Bark, et al 1990). The SIJ is appropriately described as a synovial joint as it has 5 of 6 synovial characteristics according to Bowen and Cassidy

(1980). Unfortunately, joint play testing of the pelvis is not considered as a standard physical therapy evaluation of the pelvis as evidenced by current liter­ature and educational seminars. Physical therapists can utilize an expanded evaluation that maximizes palpatory assessment, utilizes general mobility tests, incorporates testing of ligamentous tone, and adds basic and advanced spring tests. I believe that we will

then discover that the SIJ behaves somewhat differ­ently than has been proposed in the literature. In utiliz­ing this evaluation scheme, clinicians will have the tools to evaluate the movement characteristics and decide for themselves how it moves in individual clients. In some ways the SIJ seems to move (accord­ing to spring tests) in very simple and predictable ways, which renders treatment to be rather straight forward. In a small portion of clients who have sus­pected SIJ dysfunction, the pelvis can behave in a much more complex fashion as has been presented with the traditional model. What is important is that the clinician has tools available to make decisions on an individual basis.

Research on evaluation and treatment of this com­plex region is very important. Over the past decade there has been a lot of research and information shar­ing regarding this topic. There is presently ongoing research in many parts of the world. Rather than wait for the "final word" before addressing this clinical syndrome, we must utilize existing knowledge and continue to ask new questions regarding this com­plex problem, even as answers come forth. We must approach our clients with openness and diligence in attempting to assist with their complex and multi-

factorial presentations.

MICROFET is manufactured by Hoggan Health Industries and distributed by EMPI", Inc., 1275 Grey Fox Road, St Paul, Minnesota 55112

BIBLIOGRAPHY

Bark T, Rosen E, Soffer R. Basic Concepts of Or­thopaedic Manual Therapy. In: Orthopaedic and Sports Physical Therapy. 2nd ed. St Louis, C.V. Mosby; 1990:195-212.

Bernard T. 1992 Video Presentation on Sacroiliac Joint Injections. The First Interdisciplinary World Congress on Low Back Pain and Its Relation to the Sacroiliac Joint. San Diego, November 5-6.

Bowen V, Cassidy D. Macroscopic and Microscopic Anatomy of the Sacroiliac Joint From Embryonic Life Until the Eighth Decade. Spine 1980; 6:620-628.

Brooks WJ, Krupinski EA, Lund PJ 11995) Realtime Sonographic Evaluation of Sacroiliac Joint Motion Induced by Spring Testing. In: 1995 Second Inter-disciplinary World Congress on Low Back Pain: The Integrated Function of The Lumbar Spine and 'Sacroiliac Joint. Vleeming A, Mooney V, Dorman T, Snijders C (eds) San Diego, November 9-11, p 859.

Graham-Smith A, Patla-Paris C, Neville C. 1996 A Case Study: Diagnostically Confirmed Sacroiliac Joint Instability. Presented at APTA Combined Sec­tions Meeting, Atlanta, February 15-18.

Greenman PE. Principles of Manual Medicine. 2nd ed. Baltimore, Williams & Wilkins pp 93-98, 279-368.

Hesch J. 1996 Course Workbook The Hesch Method of Treating Sacroiliac Joint Dysfunction: An In­tegrated Approach. Albuquerque, Hesch J, pp 36-40.

Keating J, Matyas TA, Bach TM. The Effect on Train­ing on Physical Therapist's Ability to Apply Specific Forces of Palpation. Physical Therapy 1993; 73:38-46.

Lee D. The Pelvic Girdle. Churchill Livingstone, Edin­burgh; 1989:39-62, 107-120.

Lee D. 1992 The Relationship Between the Lumbar Spine, Pelvic Girdle, and Hip. In: First Interdiscipli­nary World Congress on Low Back Pain and Its Re­lation to the Sacroiliac Joint. Vleeming A, Mooney V, Snijders C, Dorman T (eds) San Diego, Novem­ber 5-6, pp 463-478.

Lee D. 1996 Instability of the Sacroiliac Joint and the Consequences to Gait. J Manual & Manip Ther 1996; 4(1):22-29.

Mens JMA (1992) Peripartum Pelvic Pain; A Report of the Analysis of an Inquiry Among Patients of a Dutch Patient's Society. IN: First Interdisciplinary World Congress on Low Back Pain and Its Relation to the Sacroiliac Joint. Vleeming A, Mooney V, Snij­ders C, Dorman T (eds) San Diego, November 5-6, pp 521-533.

Paris S. 1991 Introduction To Evaluation and Manipu­lation of the Spine. Institute of Graduate Physical Therapy, St Augustine, p 51.

Porterfield J, DeRosa C. 1991 Mechanical Low Back Pain. WB Saunders, Philadelphia, p 10.

Potter N, Rothstein J. Intertester Reliability for Select­ed Tests of the Sacroiliac Joint. Physical Therapy 1985;11:1671-1677.

Vleeming A, Stoeckart R, Snijders C. The Sacrotuber­ous Ligament: A Conceptual Approach to its Dy­namic Role in Stabilizing the Sacroiliac Joint. Clin Biomech 1989;4:201-203.

Vleeming A, Stoeckart R, Snijders C. 1992 Proceed­ings of The First Interdisciplinary World Congress on Low Back Pain and Its Relation to the Sacroili­ac Joint. Vleeming A, Mooney V, Snijders C, Dor­man T (eds) San Diego, November 5-6, pp 3-64.

Vleeming A, Mooney V, Dorman T, Snijders C. 1995 Second Interdisciplinary World Congress on Low Back Pain: The Integrated Function of The Lumbar Spine and Sacroiliac Joint. San Diego, November 9-11.

Walker JM. The Sacroiliac Joint A Critical Review. Physical Therapy 1992;72:903-916.

Jerry Hesch has presented over 60 workshops on the integra­tion of the sacroiliac, symphysis pubis, sacrococcygealarticula­tions and the lumbar spine. He has contributeda chapter on common patterns of SIJ dysfunction in Movement, the Pelvis and Low Back Pain: An InterdisciplinaryApproachChurchill Livingstone.