Journal of Back and Musculoskeletal Rehabilitation 26 (2013) 273–279 273

DOI 10.3233/BMR-130376
IOS Press

Sacroiliac joint dysfunction in patients with

herniated lumbar disc: A cross-sectional study
Seyed Pezhman Madania,∗, Mohammad Dadianb , Keykavous Firouzniac and Salah Alalawid
a
Department of Physical Medicine and Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
b
Department of Physical Therapy, University of Welfare and Rehabilitation, Tehran, Iran
c
Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran
University of Medical Sciences, Tehran, Iran
d
Physical Medicine and Rehabilitation Specialist, Royal National Hospital for Rheumatic Diseases, London, UK

Abstract.
OBJECTIVES: To determine the relative frequency of sacroiliac joint dysfunction in a sample of patients with image proven
lumbar disc herniation.
METHODS: A single group cross-sectional study was conducted in a three year period from 2007 in an outpatient clinic at a
university hospital. Overall, 202 patients aged more than or equal to 18 years with image proven herniated lumbar disc and with
physical findings suggestive of lumbosacral root irritation were included.
RESULTS: Overall, 146 (72.3%) participants had sacroiliac joint dysfunction. The dysfunction was significantly more prevalent
in females (p < 0.001, adjusted OR = 2.46, 95% CI = 1.00 to 6.03), patients with recurrent pain (p < 0.005, adjusted OR = 2.33
with 95% CI = 1.10 to 4.89) and patients with positive straight leg raising provocative test (p < 0.0001, adjusted OR = 5.07,
95% CI = 2.37 to 10.85). There was no significant relationship between the prevalence of SIJD, and working hours, duration of
low back pain, or body mass index.
CONCLUSIONS: Sacroiliac joint dysfunction is a significant pathogenic factor with high possibility of occurrence in low
back pain. Thus, regardless of intervertebral disc pathology, sacroiliac joint dysfunction must be considered in clinical decision
making.

Keywords: Sacroiliac joint, low back pain, lumbar disc herniation

1. Introduction if the symptoms are attributable to lumbar disc pathol-

About 70–85% of adults experience low back pain
(LBP) at some point during their life [1,2]. The disc,
facet joint and sacroiliac joint (SIJ) are potential
sources of LBP [3]. Disc-related diseases of the lumbar
spine are common causes of pain, and frequently lead
to reduced productivity and lost to work [4,5]. Lum-
bar disc herniation frequently affects the spine [6], and
∗ Corresponding author: Seyed Pezhman Madani, M.D., Assistant
Professor, Department of Physical Medicine and Rehabilitation,
Shafayahyaian Rehabilitation Hospital, Tehran University of Med-
ical Sciences, Baharestan Square, Mojahedin-E-Islam Ave, Tehran
1157637131, Iran. Tel.: +98 21 33542001; Fax: +98 21 33542020;
E-mail: p-madani@sina.tums.ac.ir.
ogy, magnetic resonance imaging (MRI) or computer-
ized tomography (CT) are indicated to confirm [7].
Diseases with the manifestations similar to those of
herniated intervertebral disc pose a challenging prob-
lem in the diagnostic workup, and in decision mak-
ing for the best treatment modality in patients with
LBP. In addition, one should be aware that dual pathol-
ogy may exist, otherwise patients may undergo clinical
and imaging investigations and the etiology may still
remain unclear. Treatment of low back pain resistant
to conservative management is still a problem. Open
surgery has disadvantages such as intraoperative tissue
damage, epidural fibrosis, and scar formation [5,8].
SIJ is a poorly defined subset of several recognized
causes of LBP. Researchers identified the SIJ as one of

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c 2013 – IOS Press and the authors. All rights reserved
274 S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc
the possible starting points of pain via injection of lo-
cal anesthetic [9]. Depending on the studied population
and diagnostic measures, the prevalence of the sacroil-
iac joint as a source of low back pain is reported 13%
to 48% in different studies [9,21,23]. In a study [24], it
has been reported that, of 1293 patients with low back
pain the SIJ dysfunction was thought to be the source
of pain in 22.5%, based on history and physical exam-
ination. Relative hypomobility of SIJ and the result-
ing pelvic asymmetry has been described as sacroil-
iac joint dysfunction (SIJD) [10,11]. The underlying
processes leading to pain production or the responsi-
ble tissues are still debated. It has been suggested that
LBP may arise from pelvic tissues or low back region
because of pelvic asymmetry and excessive or limited
spinal or SIJ motion [9,11].
It has been suggested that chronic LBP (more than
4 weeks of duration) is related to discopathies evi-
dent on MRI or CT, even in the absence of neuro-
logical manifestation. But the findings on these imag-
ing techniques are not highly correlated with those of
clinical examinations. Low diagnostic accuracy of rou-
tine clinical tests for exact detection of involved tissue
and presence of referred lower extremity symptoms are
other obstacles in the workup of LBP. Any pathology
in the SIJ that causes spasm of piriformis muscle may
lead to sciatic irritation and to a broad spectrum of
symptoms and a variety of pain radiation patterns [12].
A study showed that in 22.5% of patients, the radiation
was towards the calf and foot; the symptoms which
could be marked as radicular or discogenic pain [12].
Positional and functional clinical tests have been
developed to investigate whether SIJ is the source of
LBP. Several studies have been performed to investi-
gate the accuracy of the clinical tests [13]. Fluoroscop-
ically guided, contrast enhanced intra-articular anes-
thetic block is used as a valid test [13], but the proce-
dure is invasive, and not widely available.
Deep location, limited movement and irregular ana-
tomy are major limitations in SIJ evaluation. There-
fore, there is no single and suitable test for routine
clinical use [14] and physician should rely on a com-
bination of examinations in this regard. Treatment
strategies for SIJ lesions differ from those intended to
the pathologies of intervertebral disc, and non-specific
treatments may be inefficient [13]. Moreover, there are
still some questions about the prevalence of simultane-
ous SIJD in patients with lumbar disc herniation.
The aim of conducting this cross-sectional study was
to determine the relative frequency of SIJD in a sample
of patients with image proven lumbar disc herniation.
We hypothesized that SIJ dysfunction could be a fre-
quent concomitant pathology, with a potentially signif-
icant effect on pain and functional disability in patients
with sub acute radicular back pain and discopathy. The
rationale of the study was to decrease the possibility
of missed diagnosis of SIJD when herniation is evident
on MRI.
2. Patients and methods
2.1. Design and setting
We performed a single group cross-sectional study.
The study was conducted in a three year period from
2007 in an outpatient clinic of physical medicine and
rehabilitation at the university hospital, Shafa Yahya-
ian; a large referral orthopedic and rehabilitation prac-
tice and research center in Tehran.
2.2. Recruitment
Participants were referees from university pain, or-
thopedics and neurosurgery clinics to our referral reha-
bilitation center for diagnostic and rehabilitation con-
siderations. A board-certified radiologist read MRI
views. Demographic data, medical history and a de-
tailed history of low back pain and its possible causes
were taken at the first visit. The recruitment question-
naire asked about various lifestyle and personal char-
acteristics. A board-certified physiatrist visited the par-
ticipants, completed a detailed medical history, per-
formed physical examinations and conducted further
investigations. All patients were Farsi speaking, and
there was no linguistic confusion between participants
and the assessors.
2.3. Inclusion criteria
Patients with image proven herniated lumbar disc
and physical findings suggestive of lumbosacral root
irritation were identified and invited to participate in
the study. Briefly, patients aged more than or equal to
18 years were enrolled if they had paracentral or in-
traforaminal lumbar disc herniation on MRI. We con-
sidered “herniation” as a posterior focal extension of
the disc with sagittal image showing a narrow and dis-
tinguishable pedicle of the nucleus. Then, all patients
were assessed for positive physical signs of SIJD.
 S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc
2.4. Exclusion criteria
Patients were excluded if they were unwilling or un-
able to complete the extensive physical examination.
Pregnant women and patients with prior lumbar spine
surgery, osteoporosis, spinal or hip fractures, sever hip
joint degenerative disorders, polyneuropathy, diabetes
mellitus and patients with disc herniation producing
progressive neurological deficit signs, were excluded
from the study.
2.5. Protocols and clinical tests
At the beginning of the study all research staff were
qualified and briefed according to their tasks. Partici-
pants had been evaluated with MRI 1.5 T, Signa, GE,
USA, and had positive findings for lumbar disc her-
niation. They completed neurological, and a variety
of clinical tests for detection of SIJD including: mo-
tion, palpation, and provocation tests with some short
breaks between the examinations. Neurologic exami-
nation and the assessment of SIJD were performed by
the research physiatrist, and physiotherapist, respec-
tively.
In order to determine the side of dysfunction, an
examiner seated behind each patient and performed
sitting posterior superior iliac spines (PSIS) palpa-
tion test, with forward bending of the patient’s trunk.
The test was considered positive if a PSIS seemed to
be higher than the other, in fully flexed position. For
standing flexion test, relative heights of the PSIS were
assessed in standing position. Then the patient was re-
quested to flex forward as far as possible. A change
in the relative relationship of the PSIS in fully flexed
position was considered positive [13,15].
In Patrick-Faber test, patients were requested to lay
supine on a table, and to flex, abduct, and externally
rotate the hip of the tested leg, and the examiner placed
the lateral malleolus on the knee of the opposite leg.
ASIS was stabilized and a light overpressure was ap-
plied to the medial aspect of the knee. The range of
motion in the tested extremity was compared with the
opposite side. Aggravated pain on buttock, low back
or groin area was considered for differentiating be-
tween hip and sacroiliac joints as the origin of pain.
In addition, the evaluator checked if a difference in the
range of motion existed between the two sides [13,16,
17]. For long-sitting test, each participant was placed
in supine position with extended hips and knees. The
lengths of the inferior aspects of both medial malleoli
were compared for the assessment of levelness. Then,
275
while the evaluator held the medial border of the me-
dial malleoli with the thumbs, the patients were as-
sisted to a long-sitting position and the relative leg
lengths were evaluated again. The test was considered
to be positive, if there was any observable difference
in the relative position of medial malleoli between the
supine and long-sitting position, suggesting a posteri-
orly or anteriorly rotated innominate [15]. Gillet test
was performed with the patient standing, and facing
away from the examiner. The examiner placed one
thumb under the PSIS on the side being tested, with
the other thumb over the S2 spinous process. The pa-
tient was instructed to stand on one leg while flexing
the contralateral hip and flexing his knee toward the
chest. The test result was recorded as positive, when
the PSIS failed to move posterior and inferior with re-
spect to S2 [13,16,18]. For each participant Sphinx test
was performed in which the patient was in prone po-
sition with backward bending. Then, the assessor pal-
pated sacral sulci and inferior lateral angles. Sacral
base asymmetry was considered as positive [13].
With provocative examinations the irritation points
were assessed. The examiner applied antero-posterior
pressure on sacral base and apex; and observed for
sacral flexion and extension, respectively. Pain or
movement abnormality was evaluated with cephalic
pressure on sacrum, near the base and apex. Also, tor-
tional movement around the oblique axis was exam-
ined with pressure on the contralateral ilia of the deep
sulcus. Pressure was applied on long dorsal sacroil-
iac ligament, the anterior ligament, the sacroiliac joint
capsule, and the lumbosacral junction [19]. For the
provocative tests, elicited ipsilateral pain in the gluteal
region or below the level of L5 was considered as posi-
tive. Pain caused by pressure from the examiner’s hand
or an uncomfortable position was not recorded as pos-
itive.
Sacroiliac joint dysfunction was diagnosed if the pa-
tient had a cluster of at least four positive anatomical,
and two positive provocative tests. Range of motion
and pain on pressure were recorded, according to the
specific clinical test.
2.6. Ethical considerations
The study was conducted in accordance with the
Declaration of Helsinki, and the research protocol was
approved by the institutional review board of Tehran
University of medical sciences. The research inves-
tigators explained the aims, rationale, and safety of
the study to eligible patients. A study nurse accom-
276 S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc
panied patients and provided them with verbal infor-
mation, and a leaflet on lumbar disc herniation and
SIJD. All patients regardless of participation in this re-
search were referred for appropriate treatment. Patients
were informed that they were free to withdraw from
the study at any time.
2.7. Sample size
Sample
 size
 2calculations were based on the formula:
N = 4 ωpq2 z1−α/2 , where p is the anticipation of the
prevalence of SIJD; q = 1 − p; ω is the planned width
of 95% CI for the estimation of the prevalence, α =
0.05, and z0.975 = 1.9600. For the anticipated preva-
lence of 70%, the numbers of participants required
with ω = 0.1, and 0.2 are 323 and 81, respectively.
We were able to enroll 202 participants to provide the
planned width ω ≈ 0.12 of 95% CI for the estimation
of the prevalence.
2.8. Statistical analysis
Data were presented as mean and standard devia-
tion (STD) for continuous variables, and as numbers
and proportions for categorical variables. Chi-squared
test was used for the analysis of categorical data and
a p-value of less than 0.05 was considered significant.
Odds ratios with 95% confidence intervals were re-
ported for each contributing factor. Multivariable anal-
ysis was performed using logistic regression model to
estimate the adjusted effect of risk factors on SIJD.
Data was analyzed with SPSS for Windows, version 10
(SPSS, Inc., Chicago, IL, USA).
3. Results
We identified 202 patients who met our inclusion
criteria. They ranged in age from 19 to 70 years with
a mean (STD) age of 42 (12) years. The range of
weight was from 42 to 105 with the mean (STD) of
71 (11.4) kg weight, and the range of height was from
148 to 190 with the mean (STD) of 166.2 (9) cm. Sev-
enteen (8.4%) participants had abnormal pinprick test,
and 93 (47.2%) had diminished or absent knee and (or)
ankle reflexes. In 59 (29.2%) patients, one grade di-
minished power of ankle dorsi-flexion or plantar flex-
ion was evident in manual muscle test, and in 149
(73.8%) straight leg raising test was positive (i.e., from
30 to 60 degrees). Disc herniation was reported in 54
(26.7%), 73 (36.1%), and in 8 (4%) patients at the lev-
n=184 n=185 n=185
n=173 n=172
n=166
n=147
n=130
Percent
n=100
n=62
n=36
Fig. 1. Percent and frequency of positive clinical tests for SIJD in
202 patients with image-proven herniated lumbar disc.
els of L5/S1, L4/L5, and L3/L4, respectively. Besides,
in 67 (33.2%) participants, both L4/L5 and L5/S1 were
affected.
In our sample, 146 (72.3%) participants had SIJD,
of which 113 (55.9%) were female. Figure 1 shows fre-
quency, and percent of positive clinical tests, respec-
tively. In addition, 139 (95.2%) participants had the left
on left type of SIJD. Only in 3 (2.1), and 4 (2.7) pa-
tients with SIJD, right on left, and right on right types
were recorded, respectively.
The prevalence of SIJD was significantly higher in
women [Chi squared χ2 (1) = 10.7, p = 0.001]; crude
odds ratio (OR) = 2.84, with 95% CI = 1.5 to 5.37,
adjusted OR = 2.46 and 95% CI = 1.00 to 6.03. In
addition, SIJD was more prevalent in patients with an
abnormal straight leg raise test [Chi squared χ2 (1) =
16.3, p < 0.0001]; crude OR = 3.82, with 95% CI =
1.95 to 7.47, adjusted OR = 5.07 and 95% CI = 2.37 to
10.85. A positive history of recurrent back pain within
the last year was associated with the possibility of SIJD
by 2.4 folds [Chi squared χ2 (1) = 7.3, p = 0.005];
crude OR = 2.4 with 95% CI = 1.26 to 4.58, adjusted
OR = 2.33 with 95% CI = 1.10 to 4.89. Heavy work
load assessed subjectively by the participants was asso-
ciated with SIJD [Chi squared χ2 (1) = 6.2, p = 0.01],
crude OR = 2.27 with 95% CI = 1.18 to 4.38, but in
multivariable analysis with adjusting appropriate vari-
ables, the effect diminished in magnitude (adjusted OR
= 1.46 with 95% CI = 0.58 to 3.68). However, there
was no significant relationship between the prevalence
of SIJD, and working hours, duration of low back pain,
and body mass index (p > 0.05).
 S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc
4. Discussion
The present study was conducted to detect sacroil-
iac joint dysfunction and its prevalence as a coexisting
pathology among patients with discopathy. The results
indicated that a large number of patients with image-
proven herniated lumbar disc had SIJD. Female sex
and a positive history of recurrent back pain were im-
portant risk factors. Heavy work load was a risk fac-
tor too; the finding that may be of public health impor-
tance.
The epidemiology of the SIJ lesions has been poorly
described in previous studies. The reported prevalence
is between 13–48% [9,21,23,24]. Limited sacroiliac
joint mobility with age-induced decrement and the ab-
sence of a specific historical point or clinical exam-
ination technique have made the diagnosis of SIJD
a challenging problem. Inflammatory mediators from
disrupted capsule and multilevel innervations from an-
terior and posterior rami of L2 to S3 explain the re-
ferral pain of SIJD with variable distribution [20]. Be-
sides, there is no gold standard for the clinical diagno-
sis of SIJD, and the dysfunction is not detectable with
imaging procedures such as MRI or CT scan. Imag-
ing evaluation of SIJ is routinely done to rule out in-
fections, metabolic disorders, fractures, or tumors. But,
commonly the results are normal in patients with SIJ
pain [21].
Sacroiliac joint block has been reported as the
valid diagnostic means [19]. The controlled diagnos-
tic blocks utilizing the international association for the
study of pain (IASP) criteria demonstrated the preva-
lence of pain with sacroiliac origin in 19% to 30% of
the patients suspected to have sacroiliac joint pain [11,
20,22]. However, anesthetic block is not aimed at
extra-articular structures, the fact that may explain why
in our study the prevalence of SIJD was higher than
previously measured [20]. To our knowledge, there is
no recent study on the prevalence of SIJD in patients
with image-proven lumbar disc herniation using clin-
ical diagnostic tests. Our study was sufficiently large
and the study sample was representative of patients
with herniated lumbar disc. Combination of palpation
and provocative tests which evaluate articular, periar-
ticular and biomechanical pathologies were used for
detection of concomitant SIJD in the studied popula-
tion.
There are several studies on validity of clinical tests
with especial attention to composites of pain provo-
cation and motion - palpation tests [13,25]. It was re-
ported that the use of the manual tests of SIJD in com-
277
bination, had been informative with positive likelihood
ratio of 3.2 (95% CI 2.3–4.4) and negative likelihood
ratio of 0.29 (95% CI 0.12–0.35) [3]. All the studies
have suggested the application of multiple tests as a
reliable strategy for the diagnosis of SIJD [22,26]. In
a recent study [27], researchers highlighted inter- and
intra-examiner reliability of single and composites of
selected motion palpation and pain provocation tests
for SIJD on twenty five participants. The best reliabil-
ity was for three or more palpation together with two
or more provocation tests.
In a study [9], the frequency and significance of
SIJD in patients with low back pain and sciatica and
imaging-proven disc herniation was evaluated. They
examined 150 patients with herniated lumbar discs
of which 46 had SIJD. All patients received inten-
sive physiotherapy. The researchers concluded that in
the presence of lumbar and ischiadic symptoms SIJD
should be considered, and that in the presence of SIJD
appropriate therapy regardless of intervertebral disc
pathomorphology should be pondered. They empha-
sized that such an approach could avoid wrong in-
dications for nucleotomy [9]. Due to the absence of
newly developed reliable diagnostic clinical criteria at
the time of study, their conclusion was mostly based on
patients’ response to physical therapy for SIJ. While in
our study the more recent concept of “cluster of clini-
cal tests” has been followed.
In our study, the estimated prevalence of SIJ dys-
function was significantly higher than previous studies
(72.3%) [9,21,23,24]. This could be explained by the
importance of extraarticular factors which are not de-
tected by diagnostic blocks. However, body stress in-
duced by heavy work and poor ergonomic standards at
work place could be considered as the secondary in-
teracting factors affecting the studied population. The
other influencing factor was the examined population.
This study was conducted on patients with definite
MRI findings of discopathy.
It was found that females were more prone to the SIJ
dysfunction. Higher frequency of the SIJ dysfunction
in female patients (p = 0.001) could be due to child-
bearing effects on the sacroiliac joint [28] or other fac-
tors such as lifestyle or low exercise activities.
Past history of recurrence of same back pain within
previous year increases the possibility of SIJ dysfunc-
tion. This could mean that the recurrent back pain was
due to chronic biomechanical abnormalities which had
not been corrected, but the symptoms were transiently
subsided by adaptation [28]. Positive straight leg rais-
ing test significantly increased the suspicion of SIJD,
278 S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc
but the test could not be considered as differentiating
physical finding.
Our findings implied that SIJD is a prevalent con-
comitant pathology in patients with herniated lumbar
disc, and that SIJD can be evaluated by combinations
of easily performable palpation and pain provocative
tests. Sacroiliac joint dysfunction has been discussed
properly in manual medicine references. But, in med-
ical books on back pain the subject has not described
with sufficient details. Therefore, some physicians do
not consider SIJD as a differential diagnosis in the
work-up of low back pain [12]. According to our re-
sults, any practitioner should be aware of coincident
SIJD during evaluation of patients who apparently suf-
fer from lumbar disc herniation.
It is worth investigating whether disc herniation and
SIJ dysfunction develop independently or the patholo-
gies are interrelated. The pathogeneses are associated
with complex and asymmetrical motions and with ex-
ternal loads. Having a successful gentle manual ther-
apy to correct biomechanical defects of sacroiliac joint
and surrounding structures without any significant ef-
fect on concomitant discopathy can be considered as
a basis for future clinical trials to determine the main
pathology.
5. Conclusion
This study found the sacroiliac joint dysfunction to
be a prevalent concomitant pathology in patients with
herniated lumbar discs. Thus it recommends that SIJ
dysfunction must be considered during examination
and planning of each conservative management proto-
col in LBP patients.
Conflicts of interest
The authors declare that they have no competing in-
terests.
Source of support
The study has been supported financially by the
Tehran University of Medical Sciences.
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