How many degrees should the patient be rotated to demonstrate the sacroiliac joints?

Patrick test (FABER test)

The Patrick test is helpful in detecting limited hip motion and distinguishing hip pain from sacroiliac disease. The test is sometimes referred to by the acronym FABER, derived from the initial letters of the movements that it evaluates (flexion, abduction, external rotation) (Fig. 76.5).

With the patient lying supine, the knee and hip are flexed to 90 degrees and the foot of the examined extremity is placed on top of the opposite knee (“figure 4” position). The thigh is then slowly abducted fully and externally rotated toward the examining table. The presence of groin pain, spasm, or limitation of movement is suggestive of hip pathology. The Patrick test can also be used to stress the sacroiliac joints. To do so, one hand is placed on the abducted knee and the other on the opposite anterior superior iliac spine. Pain localized to the back when sudden pressure is applied simultaneously on each of these points suggests sacroiliac pathology.5

Petty's suggested active and passive assessment guidelines

Petty (2006) emphasizes the importance of testing each active range of hip movement (flexion, extension, abduction, adduction, medial and lateral rotation) several times and also of trying to reproduce normal function by testing combinations of movement, such as flexion with rotation or rotation with flexion. Additionally, movements can be assessed when distraction or compression is passively added to the joint and movements can be performed slowly or quickly.

Passive tests include Patrick's test (above) and also Maitland's (1991) quadrant test (Fig. 12.14).

The patient is supine, hip flexed, with the thigh on the side to be tested ‘sandwiched’ by the practitioner's forearms, hands folded over the knee and clasped together.

The leg is adducted at the hip by the practitioner who takes the flexed hip from less than 90° starting position to full flexion, while noting the range and quality of movement and any pain reported.

In this position, medial rotation and other forces such as long-axis compression can be applied to evaluate the feel and response.

Test

Instructions for manual trigger point therapy

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Treatment of mTrPs in the adductor longus: patient in supine position, Patrick test.

Treatment of mTrPs in the adductor brevis: patient in supine position, Patrick test, treatment through the pectineus/adductor longus.

Treatment of mTrPs in the adductor magnus:

patient in supine position, lower leg on therapist's shoulder,

patient lies on affected side, lower leg extended, upper leg bent.

Treatment of mTrP in the pectineus: patient in supine position, Patrick test, palpation of the femoral artery in the inguinal area, medial to the pulse palpation site the pectineus runs to the pubic bone superior branch.

Is the Sacroiliac Joint Painful?

There are many tests that attempt to stress the SI joints. The FABER test (Flexion, ABduction, and External Rotation) is also known as the Patrick test, but the ankle-to-knee or heel-to-knee test is the most common term for it. With the patient in the supine position, the affected hip is externally rotated with the knee flexed, so that the affected ankle can be placed on top of the opposite knee in a number-four position. Applying downward pressure to the affected knee stresses the hip joint and may cause typical hip pain. In the absence of hip pathology, when the pelvis is stabilized by applying pressure over the opposite iliac crest, the affected SI joint is stressed (Figure 5-25). Pain in the gluteal region of the stressed side is considered a positive test.

The Gillet test evaluates the amount of SI motion in the coronal plane. With the patient standing, the examiner palpates the spinous process of S2 with one hand and the PSIS with the other. As the patient flexes the hip on the side being evaluated, the PSIS should normally move posteriorly and inferiorly with respect to S2. Absence of movement suggests sacroiliitis with fusion of the joint.

FABERE Test

FABERE is the acronym that describes the positioning of the hip used during this test, which is flexion, abduction, external rotation, and extension. This test is also known as the Patrick test and is often referred to as the FABERE Patrick test. A US neurologist and neuropsychiatrist who practiced in the late 1800s is credited for first describing the test, though the original description was not found. The purpose was to identify patients with hip arthritis through the application of compressive forces to the hip cartilage to induce pain.31,37

The patient is placed in the supine position and the examiner flexes, abducts, and externally rotates the hip being tested, ending with the ankle resting on the contralateral knee (Figure 8-7). The examiner then stabilizes the pelvis by applying pressure to the contralateral ilium. Pressure is then applied in a posterior direction to the knee causing further external rotation at the hip. The test is considered positive for hip joint pathology if this positioning recreates the patient's groin pain. This test also stresses the sacroiliac joint, pubic symphysis, adductors, lumbar spine, and inguinal ligament. Therefore, if the test provokes pain, the examiner must ask the patient to specify the location of the pain to help determine the sight that is problematic. If the test reproduces posterior pelvic pain contralaterally, it is considered a positive test indicating that the sacroiliac joint is involved. A positive test that reproduces groin pain may indicate that there is a dysfunction within the hip joint, but does not specify the particular pathology.

The reliability, sensitivity, and specificity of this clinical test have not been studied.

Axial Skeleton

Involvement of the joints of the axial skeleton is characteristic. In children with sacroiliac inflammation, pain may be elicited by direct pressure over one or both sacroiliac joints, compression of the pelvis, or distraction of the sacroiliac joints by Patrick test (Faber test). Examination of the back may demonstrate abnormalities in contour, such as loss of the normal lumbar lordosis, exaggeration of the thoracic kyphosis, or increased occiput-to-wall distance. The contour of the back on full forward flexion may demonstrate loss of the normal smooth curve in the lower part of the thoracolumbar spine (Fig. 17–3), or there may be restriction of hyperextension, signifying early axial disease. The rigid spine of long-standing AS is rare in children. Cervical spine involvement is also a late development.146 Although observations of abnormalities of the contour of the back are often more informative than actual numerical measurements, sequential measurement of thoracolumbar mobility is useful in documenting progression of the disease.

The modified Schober test147,148 provides one index of abnormality (Fig. 17–4). With the child standing with the feet together, a line joining the dimples of Venus is used as a landmark for the lumbosacral junction. A mark is made 5 cm below (point A) and 10 cm above (point B) the lumbosacral junction. With the patient in maximum forward flexion with the knees straight, the increase in distance between points A and B is used as an indicator of lumbosacral spine mobility. Normal values plus or minus 1 standard deviation are indicated in Figure 17–5. In general, a modified Schober measurement of less than 6 cm (e.g., an increase from 15 cm to less than 21 cm) should be regarded as abnormal. However, care should be exercised in interpreting this measurement, because there are large normal variations at each age and the data have not been adequately validated in children with musculoskeletal disease. Measurement of the distance from the fingertips to the floor on maximum forward flexion is often used to quantitate spinal motion but is poorly reproducible and does not correlate with the Schober measurement. Furthermore, finger-to-floor distance reflects hip as well as back flexion.

Thoracic disease may be reflected in limitation of chest expansion. Normal thoracic excursion varies a great deal, and normal age- and sex-adjusted ranges have not been established. However, in a specific child, sequential measurement of thoracic motion may be useful in documenting progressive loss of range. In the adolescent, any thoracic excursion of less than 5 cm (maximum expiration to maximum inspiration, measured at the fourth intercostal space) should be regarded as probably abnormal. Even in the absence of symptoms, chest expansion in children with JAS may be restricted to 1 or 2 cm. Pain and tenderness at the costosternal and costovertebral joints may be elicited by firm palpation. Sternomanubrial tenderness sometimes occurs, but sternoclavicular pain is more common.

PAIN PROVOCATION TEST FOR THE ANTERIOR LIGAMENTS

The FABER test (Fig. 14.12) assesses mainly the anterior ligaments and derives its name from the combination of movements applied, being Flexion, ABduction and External Rotation of the hip. It is also known as Patrick's test or the ‘4-test’ because of the resultant position of the limb.

Perform the test on the pain-free side first for subsequent comparison. With the patient in supine lying, the foot of one leg is placed on the knee of the other and the leg allowed to rest in lateral rotation and abduction. An assessment is made of the range of movement which is usually limited in sacroiliac joint problems. Pain reported at this stage is more likely to be indicative of hip joint pathology. Stabilize the opposite side of the pelvis and stress the sacroiliac joint by placing gentle downward pressure on the flexed knee. Pain now reported in the back incriminates the sacroiliac joint as a cause of symptoms (Hoppenfeld 1976).

Most authors agree that pain provocation tests are more reliable than palpation tests for sacroiliac joint dysfunction (Kokmeyer et al 2002). However, no individual pain provocation test has sufficient reliability or validity, leaving this a controversial topic. A battery of tests is used in clinical practice and it is commonplace to select three or four individual tests (Broadhurst & Bond 1998, Chen et al 2002).

Dreyfuss et al (1996) attempted to validate 12 commonly used tests by intra-articular diagnostic blocks using a stringent criterion of 90% relief of pain on re-assessment. The tests assessed failed to show diagnostic value, but four tests proved the most sensitive in this study in the following order: (1) sacral sulcus tenderness; (2) pain over the sacroiliac joint; (3) buttock pain; (4) patient pointing to the posterior superior iliac spine.

Broadhurst & Bond (1998) included the FABER test in their study, determining it to have a high degree of sensitivity and specificity. Van der Wurff et al (2000) present a systematic methodological review of reliability studies for pain provocation and motion palpation tests, identifying nine studies with acceptable methodological scores. The thrust test using the femur as a lever and Gaenslen's test (see below) seem to have the greatest reliability. However, the results were not shown to be uniformly reliable and van der Wurff et al (2000) suggest that upgrading the methodology of the tests would not have improved the results.

Laslett & Williams (1994) assessed the reliability of various provocation tests and found that the distraction, compression, posterior thigh thrust and pelvic torsion tests (Gaenslen's test) have the greatest inter-therapist reliability out of seven tests assessed, but that these need to be studied further in order to establish their diagnostic power.

Freburger & Riddle (2001) found some support in the literature for the following pain provocation tests: FABER test, palpation over the sacral sulcus, thigh thrust or posterior shear test, resisted hip abduction, iliac compression and gapping. They suggest that in the absence of stronger evidence, positive pain provocation tests together with the patient's descriptive information on pain referral patterns are used towards diagnosis of sacroiliac joint dysfunction.

Kokmeyer et al (2002) recruited 78 subjects in a study to determine the reliability of a multitest regimen of five sacroiliac joint pain provocation tests for dysfunction. They describe the tests, but suggest that they have been modified, which raises the issue of standardization. They conclude that better statistical reliability could have been achieved by using the five tests in combination, rather than the individual tests themselves, and advocate a regimen of three positive indicators in the five tests. Levin et al (1998, 2001) also raised standardization issues by examining the consistency of force variation and force distribution during pain provocation tests and their importance to pain response. They concluded that force registration would be a step towards standardizing the pain provocation tests.

The controversial issues discussed above mean that a number of different tests are described in various sources, many of them variations on a common theme. In order to apply current evidence, the thrust tests using the thigh as a lever, the FABER test and Gaenslen's test are currently supported by some evidence. Other tests should be recognized as a guide until reliability and validity are confirmed. It must also be acknowledged that the pain provocation tests are non-specific because they stress a number of adjacent structures around the hip, the lower lumbar spine and the sciatic and femoral nerves (Chen et al 2002). Diagnostic injection under fluoroscopic guidance is considered to be the gold standard for diagnosis, but has the disadvantage of being an invasive procedure and is not therefore used as a first line assessment tool (Calvillo et al 2000, Chen et al 2002).

Evaluation of the Hip Joint

Inspection of the hip joint should pay attention to symmetry, muscle bulk, and surgical scars. Normal range of motion at the hip is 100 degrees of flexion, 30 degrees of extension, 20 degrees adduction, and 40 degrees abduction. With the hip joint in flexed position, range of motion is 45 degrees for internal rotation and 40 degrees for external rotation. Hip pain may result from pathology of the acetabulum, femoral neck or head, periosteum, or joint capsule. It may also result from abnormalities of a surrounding structure such as bursae or may be referred from the lumbar spine or sacroiliac joint. Hip joint pathology usually results in pain in the groin, anteromedial thigh, or laterally over the greater trochanter region.

Pain referral patterns alone are often insufficient to diagnose the etiology of hip pain and an appropriate imaging evaluation is helpful in this regard.