The

Symptomatic
SI Joint
Clinical
Examination,
Diagnosis and
Treatment

1
Biagio Mazza, PT
DPT, MPT, OCS, SCS, COMT, CSCS, NSCA-CPT

• MPT - 2001, Rockhurst University, KC, MO

• DPT - 2010, EIM Institute of Health
• APTA Board Certified – Orthopedics and Sports
• Certified Orthopedic Manual Therapist (Spine) – IAOM
• Private Practice Owner: Elite Physical Therapy, KC,MO
• Residence: Prairie Village, KS
• 2 Boys – Anthony 10, Christian 6

• Paid consultant of SI-BONE, Inc.

2
Genne’ DeHenau McDonald PT
• Physical Therapy Degree 1989
• Oakland University, Rochester, Michigan

• 26 years clinical experience

• Former Adjunct Faculty and Clinical Lecturer

• University of Florida DPT Curriculum

• Former Faculty Herman and Wallace Pelvic Health Institute

• Publications
• Musculoskeletal LBP During Pregnancy
• Piriformis Syndrome

• Program/Project Manager Medical Affairs SI-BONE

Course Objectives
1. Understand the prevalence of SI joint pain.

2. Review anatomy and biomechanics of the SI joint.

3. Review the integrated model of SI joint function.

4. Understand the relationship between the lumbar spine, SI joint and hip.

5. Review subjective history for patient with SI joint pain.

6. Correctly perform SI joint provocation testing

7. Review SI joint rehabilitation.

4
Prevalence of SI Joint Pain
Is the SI Joint truly a problem?

15-30% 32-43%
Component of LBP Symptomatic Post-Lumbar Fusion
35%

30.0%
30%
27.0%
25%
22.6%

20% 18.5%
DePalma – Pain Med 2011

15%
14.5%

10% 32% Katz 2003

5%
35% Maigne 2005
43% DePalma 2011
0%
Bernard Schwarzer Maigne Irwin Sembrano 40% Liliang 2011
1987 1995 1996 2007 2009

5
SIJ & Adjacent Segment Degeneration

75% of post lumbar

fusion patients showed
SI joint degenerative
changes on CT scan five
(5) years after lumbar
fusion. Ha et al 2008

Lumbar fusion leads to

increases in angular
motion and increases in
joint stress at the
sacroiliac joint. Ivanov et al 2008

6
Anatomy
Sacroiliac Joint

Articular Surface

7
Anatomy
Anterior Ligaments Posterior Ligaments

8
Biomechanics

Nutation
Nutation
Sacral base movement
anteroinferior
Counternutation
Sacral base movement
posterosuperior
Translation
Linear motion; motion in
any one direction
Counternutation

Forst 2006

9
SI Joint Motion
Multi-planar motion
– Simultaneously rotate and
translate through 3 axes of motion

Motions (<4° in any plane)

– Nutation/Counternutation
• Primary motion
Males: 1 - 2°
Females: 2 - 4°

Sacral Translation
– (A-P motion) up to 1.6mm

Sturesson 1989

10
Integrated Model of SI Joint Function

• Describes effective transfer of force and load across the SI

joint from the lower extremities to the spine.
Snijders & Vleeming 1993

• Requires a stable core (lumbar spine, pelvis and soft tissues)

• 3 Components of Functional Stability

Passive (form closure)
Active (force closure)
Neuromuscular Control (motor control)
Panjabi 1992

11
The Integrated Model of SIJ Function

Components
Form Closure/Structural Motor Control: Nervous system
Integrity: The shape of the coordination / co-activation of
sacrum and the integrity of deep stabilizing muscles
the supporting ligaments (onset, duration, timing)
contribute to SI joint stability Snijders 1993, Hodges 1996, Richardson 2002

Lee 1998, Vleeming 1990a, Vleeming 1990b

Force Closure/Joint
Compression: The external
dynamic forces created by Core muscles should contract
contraction of the stabilizing before load reaches the low
muscles and their fascial and back and pelvis to prepare the
ligamentous attachments system for impending load.
Lee 1998, Vleeming 1990a, Vleeming 1990b

12
Form Closure
Osseous Structures – Macro, Micro
Supporting Ligaments

13
The Integrated Model of SI Joint Function:
Force Closure – Local Muscles
Local System: contracts prior to upper/lower limb movement
regardless of direction Hodges 1997, 2003; Hodges & Richardson 1997; Hodges 1999; Moseley 2002,2003

Local Core Muscles

• Transversus Abdominus
• Multifidus
• Pelvic Floor Muscles
• Diaphragm
– More research being done on
other contributing muscles

14
The Integrated Model of SI Joint Function:
Force Closure – Global Muscles

Global System:
Contracts later and is direction dependent
Radebold 2000, 2001; Hodges 2003

Vleeming’s slings:
Large Muscle Groups and their Fascial
Connections
– Posterior Oblique System
– Anterior Oblique System
– Deep Longitudinal System
– Lateral System

Radebold 2000, 2001; Hodges 2003

15
Thoracolumbar Fascia & Paraspinal Muscles

Caudal part of the TLF, in combination with efficient paraspinal

muscles, plays major role in force closure of SI joint

Macintosh & Bogduk – Spine 1993, Vleeming – Spine 1995

16
Motor Control
• Optimal force closure of the SI joint
• Studies showing alteration of muscle activation
patterns in low back, groin, and SI joint pain
populations
– TrA Delayed in LBP Hodges & Richardson 1996

– TrA Delayed in Groin Injuries Cowen 2004

– Altered Motor Control with SI joint Pain O’Sullivan 2002

• Timing, sequence and amplitude of muscle firing

– Afferent input from receptors in joints, ligaments, fascia and muscles
– Efferent response of central and peripheral nervous systems Hodges 2003

17
 Evaluation of the
Patient with
Sacroiliac Joint Pain

18
Can we diagnose SI joint pain?

• Common pain patterns from multiple conditions

– Spine (stenosis, facet, spondy, disc herniation, DDD, etc.)
– SI Joint
– Hip (OA, FAI, early AVN, etc.)
– Pelvis (Glut tear, piriformis, pelvic floor)
• Imaging not routinely helpful
• History and Physical Examination
− Provocative maneuvers Laslett 2005, Szadek 2009
− SI joint ROM & Position testing not reliable Freburger 1999, Robinson 2007

• Diagnostic Injection

19
Lumbar Spine – SI Joint – Hip
Pain Referral Patterns
Isolated
Spinal Stenosis SI Joint
Hip Pathology
Buttock common Buttock, PSIS (94%) Buttock pain (71%)

Groin uncommon (except L1, L2) Groin not uncommon (14%) Thigh and Groin (55%)

Lower extremity common Lower extremity common (28%) Knee or below (47%)

Lateral hip – common Lateral hip & thigh common Lateral hip – common

Lumbar region common Lower lumbar region (72%) Lumbar pain uncommon

Devin – JAAOS 2012 Vanelderen – Evid Based Med 2010 Devin – JAAOS 2012

20
Potential Causes of SIJ Pain: Traumatic

• MVA: Foot on Brake

• Slip and Fall

• Lifting and Twisting

• Traction Injuries

21
21
Potential Causes of SI Joint Pain: Gradual Onset

• Laxity of the SI joint / Pregnancy

• Repetitive Forces on SI joint and
Supporting Structures

• Biomechanical Abnormalities
– Leg length inequality
– Pelvic obliquity/scoliosis
– Iliac crest bone graft

• Adjacent Segment Degeneration

– After lumbar spinal fusion

• Post Infection Degeneration

22
22
Hip and Adjacent Segment (SI Joint)

Hip and SI Joint 42% Hip OA

76% (25/33) of patients with 45% Subchondral cyst
symptomatic SI joint
pathology had at least one 21% Retroversion
abnormal finding on hip 12% Lateral CE* angle >40%
radiograph
47% Coxa profunda
A significant number met the strict 33% Cam impingement
diagnostic criteria for FAI.
* Center Edge

Morgan 2013

23
Elements of the Diagnosis

Positive Positive SI Joint

Subjective Provocative
History Testing

Lumbar Spine Positive Response

and to Intra-articular
Hip Exam Injection

24
History and Complaints

HISTORY COMPLAINTS
• When did the pain start? • Lower back pain
• Prior trauma • Sensation of numbness, tingling or
weakness
– A fall on the buttock
• Pelvis / buttock pain
– Car accident
(T-bone, rear-end, head-on) • Hip / groin pain
– Lift/Twist • Feeling of leg instability, buckling, or
giving way
– Other
• Disturbed sleep patterns
• Prior lumbar fusion
• Disturbed sitting patterns (unable to sit
– Prior iliac bone graft harvest for long periods, on one side)
• Pregnancy • Pain going from sitting to standing

25
25
History: SI Joint Pain Presentation

Pain Diagram
• Pain in buttock and posterior thigh
– Usually not midline
– Usually below L5
– At or lateral to PSIS
– Occasionally groin
• Secondary pain in lateral thigh,
groin, and/or lateral calf

Fortin 1999

26
26
Exacerbating Activities
Pain with Transitional Motions
- Supine to painful side
- Sit to stand
- Rolling over in bed
- Getting in /out of bed
Pain while Stationary
- Sitting on affected side
Unilateral Weight Bearing - Prolonged standing/sitting
- Putting on Socks/Shoes
- Ascending/Descending Stairs
- Getting in and out of Car
- Prolonged Walking
(85% of gait cycle is single leg stance)
Janda 1983

Sexual Intercourse
27
27
Relieving Activities

• Bearing weight on
unaffected side

• Lying on unaffected side

• Manual or belt stabilization

28
28
Lumbar Spine – Hip – SI Joint
Physical Examination

29
Assess Lumbar Spine: Facet Joint Pain

• Incidence 10-15% in patients with chronic LBP

Saravanakumar 2008

• Low back pain from the facet joints:

radiates down into the buttocks and posterior thigh.

• Clinical Findings
– Point tenderness overlying the inflamed facet joints
– Loss in spinal muscle flexibility (guarding)
– More discomfort leaning backward than forward.

• No history findings or examination maneuver

has been found to be unique or specific to this
entity Kayser 2008, Cohen 2007, Jackson 1998

30
Assess Lumbar Spine: Disc-Related Pain

The McKenzie Procedure

• More accurate than MRI in:
– Differentiating discogenic from non-discogenic LBP
– Differentiating contained from non-contained discs
(Donelson 1997, 1990)

• Measures patient's symptomatic response to

repeated end-range movements

• Discogenic pain is associated with centralization

with repeated end range movements
(Young 2003, Hancock 2007)

• Most common direction of testing that centralizes

pain is extension

31
Assess Lumbar Spine: Physical Exam

Standard tests to rule out

lumbar radiculopathy
• DTRs
• Neuro Exam

Passive Straight Leg Raise

To rule out lumbar radicular pain + at 35-70°
• Sensitivity 91%
• Specificity 26%
Deville 2000
These can all be
Slump Test performed quickly
To rule out lumbar disc herniation's in supine before
• Sensitivity 84% performing
• Specificity 83% provocative testing
Majlesi 2008 for the SI joint.

32
Assess Hip: Physical Examination
FABER: For Intra-articular hip pathology (if pain anterior)
• Hip flexion, abduction and ER with overpressure
• 88% sensitive (Martin 2005)
Scour: For Hip OA and other pathologies
• Sensitivity 62% - 91%
• Specificity 43% - 75%
(Konin 2006, Magee 2008)

FADIR: For FAI and labral tears:

• Hip flexion, adduction, IR
• Sensitivity = 75%,
• Specificity = 43% (Austin 2008)
FAIR: For Piriformis Syndrome (assure pain is posterior)
• Sensitivity 88%
• Specificity 83% (Fishman, 2002)

33
Assess Hip: Physical Examination

Range of Motion Testing of the Hip (Birrell 2001)

• The most predictive finding for osteoarthritis is decreased range of motion with
restriction in internal rotation
• For those patients with one plane of restricted movement, the sensitivity for
severe osteoarthritis is 100% and specificity is 42%
• Used to rule in/out osteoarthritis

Femoral Neck Anteversion (FNA) Assessment

Compare bilaterally
• If IR is 30 degrees > then external rotation, predictor of FNA (Swanson 1963)

• Trochanteric Prominence Angle Test (TPAT) or Craig test

TPAT predicted the FNA measured intraoperatively, more accurately than either the CT
or Magilligan method (Ruwe 1992)

34
Assess Hip: OA & FAI
• There is a strong association between early hip OA (osteoarthritis) and FAI
(femoral acetabular impingement)
• Altman Criteria for Hip OA:
– Hip IR > 15 degrees, Pain with Hip IR
– Morning stiffness for < 60 min and Age > 50 years OR
– Hip IR < 15 degrees, and Hip Flexion < 115 degrees
– (Sensitivity 86 % Specificity 75 %) Altman 1991

• Patients with hip OA often develop osteophytic changes and bony over-
growth of the acetabular rim and femoral head
• This would create FAI in and of itself Chibulka 2009, Phillippon 2007

Clinical Presentation
• Both may present with positive tests for FABER and FADIR
• Both may present with a decrease in hip flexion and internal rotation (ROM)

35
Assess Hip: FAI (Femoral-Acetabular Impingement)

Contact between the femoral head-

neck junction and the acetabular rim Confirmation
• Arthroscopy: Gold Standard
• Insidious onset 50% of cases Samora 2011
• MRI
• Symptoms
– Persistent insidious deep groin, lateral hip
or buttock pain
– Pain increased with prolonged sitting or
standing and hip flexion-type movements
– Decreased hip ROM

Two Types
• CAM (More common in young males)
– Anterior-superior aspect
• Pincer (More common in females)
– Anterior acetabular labrum and chondral
injury in posterior-inferior acetabular rim
Ganz 2003

36
Assess Hip: Labral Tear Clinical Findings

• Morphological changes in proximal femur or acetabulum

lead to abnormal contact during hip flexion Samora 2011

• Clinical Symptoms: anterior groin pain (96-100%),

clicking, locking (58%), catching, instability, giving way
and/or stiffness Martin 2006, Lewis 2006
– Predisposing factor: Coxa Valga = 87% of cases

• Clinical Sign: FADIR TEST

Method of Injury – Hip external rotation + extension, direct trauma, abnormal loading patterns
MRI – May demonstrate labral tear, but often the bony articular pathology are missed
MRA – Gold standard is magnetic resonance arthrogram Samora 2011

37
Assess Hip: Piriformis Syndrome

Piriformis compresses or irritates the sciatic nerve Magnetic Resonance Neurography:

• Incidence: 17.2% among low back pain patient Type of MRI that highlights
Chen 2013
inflammation and compression of
Clinical symptoms the nerves.
• A dull ache in the buttock. Filler 2005
• Pain down the back of the thigh, calf and foot
(sciatica)
• Pain when walking up stairs or inclines.
• Increased pain after prolonged sitting.

Clinical Sign
• FAIR Test: Reproduction of symptoms when
piriformis muscle is put on stretch.
(hip flexion, adduction and internal rotation)
Fishman 2002, Loren 2010

38
Assess Hip:
Gluteus Medius & Minimus Tears
Incidence
• Common finding on MR imaging in patients
with buttock, lateral hip, or groin pain.
Kingzett-Taylor 1999

Clinical Symptoms
• Dull lateral hip pain, buttock or groin pain

Clinical Signs
• Focal tenderness at the gluteal insertion
• Weak hip abduction
• Pain with passive and then resisted hip
internal rotation with the hip flexed to 90°
Sen 88%, Spec 97.3%

• Pain on one-legged stance for 30 sec or more

Sen 100 % Spec 97.3%
Lequesne 2008

39
SI Joint: Physical Exam
Fortin Finger Test
Point to pain while standing
• Able to localize pain with one finger
• Within 1 cm of PSIS (inferomedial)
• Consistent over at least 2 trials

Ask patient to point to

location of primary pain

• Below L5: Consider SI joint

• Above L5: Consider lumbar
spine etiologies

Fortin & Falco 1997

40
SI Joint: Physical Exam

Active Straight Leg Raise

To assess functional pelvic stability

• Sensitivity: 87%
• Specificity: 94%
Mens 2001

41
SI Joint: Provocative Tests

The following five provocative tests, when

performed in combination are proven to
have a high degree of sensitivity and
specificity:

1. Distraction* (Highest PPV**) Laslett Szadek

2. Thigh Thrust* 3 or more positive tests

3. Compression* Sensitivity 91% 85%

4. FABER Specificity 78% 76%
5. Gaenslen’s Maneuver
* Most sensitive of tests
** PPV = positive predictive value

Laslett 2005, 2008

Szadek 2009
42
42
SI Joint: Specificity of Provocative Tests

How to Interpret Your Results

1 Positive Test = Suspicion
2 Positive Tests = Fair Confidence
3+ Positive Tests = High Confidence

• Specificity increases when symptoms don’t centralize or peripheralize

with thorough, multidirectional repeated movement assessment
(McKenzie Assessment)
• In some cases a patient may not tolerate having five (5) tests
performed. Therefore, it’s recommended that the three (3) most
sensitive, specific and reliable tests be performed first.

Laslett 2005, Laslett 2008, Szadek 2009

43
SI Joint: Provocative Tests
Distraction Thigh Thrust

FABER Compression

Gaenslen’s Maneuver

44
SI Joint: Provocative Test Tips
 Assure the tester position is above the patient by lowering table or
standing on a sturdy stool in order to provide adequate force.

 Start with light pressure and gradually increase, keeping

hands
cupped to minimize local contact pressure (30 second max).

 Keep arms straight and lean forward with your upper body to create
gentle steady force.

 Stabilize patient on the table to prevent muscle guarding.

 Stabilize contralateral ASIS during Thigh Thrust and FABER tests.

 If pain is provoked with test, ask patient to identify pain location to

confirm it is their typical pain.

45
SIJ Region Pain – Myofascial Causes

• Quadratus Lumborum

• Gluteus Maximus

• Piriformis

• Levator Ani
Travell and Simons 1992

46
Justification for SI Joint Injection

Negative Positive Fortin Positive Pain

Positive
Lumbar and Finger Test Provocative
History
hip exam and Physical Tests
Exam

47
47
What’s the Reference Standard for Diagnosis?

Injection Under Fluoroscopy

Diagnostic Injection
• Confirm with contrast and
imaging
• Low volume, local anesthetic
• 50-75% pain reduction

Therapeutic Injection
• Local anesthetic + corticosteroid
• May provide intermediate or long
term relief
• Results of therapeutic injections
can be unpredictable

48
48
Injection Assessment

• Patient pain diary

• Significant positive clinical response
– 50-75% VAS reduction indicates positive diagnosis of SI
joint as pain generator
– Obtain copy of arthrogram to ensure accuracy
• Equivocal or no relief
– < 50% VAS reduction indicates a non-significant clinical
response
– May have SI joint pain, but consider other pain sources

49
49
Conservative Treatment
Options for
Sacroiliac Joint Pain

50
Conservative Treatment Options

Symptom Management
• Medications (non steroidal anti-inflammatories,
oral steroids, pain medications)
• External SI joint stabilization with belting
• Therapeutic SI joint injections (1-4 per year)
• Physical Therapy

Sembrano 2011
Cohen 2005

51
Conservative Treatment Options: Goal
Treat the joint by returning it to its normal relationships
so outcomes may be enhanced. Fife 2008

• Optimal SI joint function occurs with the SI Joint in

neutral (mid-range) position.
DonTigney 1990, 1994, 1999, 2005; Fujiwara 1999;
Pool-Goudzwaard 2001, 2003; Snijders 1993, 2004; Vleeming 1996

• Treatment goal should be restoration of normal

movement and SI joint position.

52
Conservative Treatment Options:
Physical Therapy
• Modification of Activities of Daily Living (ADLs)
– specific focus on activities that may create or exacerbate symptoms.

• Patient education regarding maintaining optimal alignment

with positioning, posture and body mechanics

• Stabilization Exercise/ Neuromuscular Re-education

– Specific focus on timing and engagement of local and global core muscles
Snijders 1993a, 1993b, Hodges 1996, Richardson 2002

53
Conservative Treatment Options:
Physical Therapy
• Achieve normal muscle strength balance where
existing deficits (include gluteus medius assessment)
Lee 1998, Vleeming 1990, Vleeming 1989

• Achieve normal muscle length balance where existing

imbalances exist
– Consideration of muscles that attach to the ilium and sacrum directly and
indirectly, especially limiters of hip internal rotation.
Cibulka 1998, Lee 1998, Vleeming 1990, Vleeming 1989

• Adjacent segment joint and soft tissue restriction

mobilization and manipulation as needed *
– Consider the hip structures, lumbar and thoracic regions, knee and ankle
joints.

54
Conservative Treatment Options:
Physical Therapy
• Manual techniques to address myofascial pain

• Balance assessment and training

• Gait training

• Regain or maintain cardiovascular health

• Modalities for pain and muscle spasm

55
Surgical Treatment Options
for
Sacroiliac Joint Pain

56
Treatment Options: Surgical

Smith-Petersen 1926 Campbell 1927 Gaenslen 1927

Bloom 1937 iFuse 2008

57
57
MIS SI Joint Fusion Technologies

Examples of existing SI-BONE:

iFuse Implant System®
and/or developing
technologies. Globus:
SI-LOK Joint Fixation System
The iFuse Implant
Medtronic:
System is the only Rialto Sacroiliac Joint Fusion System
technology supported
by published clinical VG Innovations:
SiJoin Posterior Sacroiliac Joint Fusion System
evidence.
(May 2015) X-spine Systems:
Silex Sacroiliac Joint Fusion System

Zyga Technology:
SImmetry Sacroiliac Joint Fusion System

58
iFuse Implant System®

• Unique Design
Triangular shape – minimizes rotation
Interference press fit
Porous TPS coating – large surface area
Specifications
• 3X stronger than screw
(iFuse vs. 8.0mm cannulated screw, Mauldin 2009, SI-BONE)
• 31X rotational resistance greater than screw
(Torsional Rigidity, iFuse vs. 7.3mm screw, 300191-A, SI-BONE)

• Strength of Experience and Focus

17,000+ procedures worldwide (September 2015)

Outstanding training programs

Knowledge in the OR
Reimbursement support

• Clinical Evidence

59
iFuse Procedure Overview

Incision Pin Soft Tissue Protector Measure

Drill Broach Insert Implant Repeat

60
iFuse Implant System® Publications

I …....................... 2 RCT (INSITE, 102 iFuse vs. 46 NSM)

IIb …................. 3
Prospective, multicenter (SIFI)
Systematic Review

III …............. 3 Open vs. iFuse

IV ….… 10 Retrospective case series

Clinical – Other ...... 2

Complaints analysis
Intraoperative neuromonitoring

Stability achieved & maintained post-cycles

Biomechanics ... 2 Implant placement technique comparison

Complete References in Bibliography

Proprietary and Confidential. 61
Rapid and Sustained Pain Relief –VAS SIJ Pain
VAS SI Joint Pain

Complete References in Bibliography

Proprietary and Confidential. 62
Complete References in Bibliography
Proprietary and Confidential. 63
Complete References in Bibliography
Proprietary and Confidential. 64
Post-Operative Considerations

Individual Treatment Plans Post Surgical Decisions

Considerations:
• Age • Plan for protected weight
• Weight bearing
• Bone quality • Activity limitations
• Associated health factors • Post op rehab plans
• Plan for return to activity

65
65
Post-Operative Guidelines

To assist HCPs with

Patient Education

66
Post-Operative Guidelines and Precautions

Weight-bearing Status

Post-Operative Swelling Prevention

Precautions and Activity Guidelines

67
Circulation and Stabilization Exercises

Description of Core Strengthening

Exercises for DVT Prevention

combined with basic core
strengthening

68
Bed Mobility, Transfers and Stairs

Patient is instructed in maintenance of

neutral lumbopelvic mechanics with
movement and utilization of TrA
muscle to assist with stabilization

69
Post-Operative Physical Therapy Considerations

Review of common musculoskeletal

problems affecting the SI joint or
affected by chronic SI disorders

Suggested areas to address post-

operatively based on best practice and
current evidence

70
Post-Operative Considerations

Patient Education: Positioning, Posture and Body Mechanics

Gait Training

Balance Assessment and Training

Timing and Engagement of Core Local/Global Stabilizers

Achieve Normal Muscle Strength and Length Balance

71
Post-Operative Considerations

Eliminate Restrictions in Adjacent Structures

• Hip Capsule
• Lumbar and Thoracic Spine / Knee and Ankle Joints

Retraining of Functional Movement Patterns/Motor Control

• With Activities of Daily Living
• With Recreational Activities in Patient Population

Regain / Maintain Cardiovascular Health

72
Conclusion

• SI joint can be painful: pathology is prevalent

and underdiagnosed

• SI joint stability depends on a complex

integrated system – Form and Force Closure,
Motor Control

• Must understand the lumbar spine-SI joint-hip

complex and how they interact

73
Conclusion
• Diagnosis of SI joint pain
– History
– Physical Examination of spine, hip and SI joint
– Correct Performance of SI joint provocative tests

• Treatment options for SI joint pathology

– Non-surgical management
– Surgical option – MIS SI joint fusion
– Pre and post-operative considerations

74
75
The iFuse Implant System® is intended for sacroiliac fusion for conditions including
sacroiliac joint dysfunction that is a direct result of sacroiliac joint disruption and
degenerative sacroiliitis. This includes conditions whose symptoms began during
pregnancy or in the peripartum period and have persisted postpartum for more
than 6 months.

There are potential risks associated with the iFuse Implant System. It may not be
appropriate for all patients and all patients may not benefit. For information about
the risks, visit: www.si-bone.com/risks

One or more of the individuals named herein may be past or present SI-BONE
employees, consultants, investors, clinical trial investigators, or grant recipients.
Research described herein may have been supported in whole or in part by SI-
BONE.

SI-BONE, SI University and iFuse Implant System are registered trademarks of SI-BONE, Inc.
© 2015 SI-BONE, Inc. All rights reserved.

U.S. Patent Nos. 8,202,305; 8,840,623; 8,986,348; and 9,039,743; pending U.S. and foreign patent applications
9228.061815

76
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Austin AB., Souza R.B., Meyer J.L. and Powers C.M. (2008) Identification of abnormal hip motion associated with acetabular la bral pathology. Journal of Orthopedic and Sports Physical Therapy , 38(9): 558-565.

Barker P J, Briggs, CA, Bogeski G 2004 Tensile transmission across the lumbar fascia in unembalmed cadavers. Spine 2004;29(2):129-38.

Beatty RA. The piriformis muscle syndrome: a simple diagnostic maneuver. Neurosurgery. 1994;34:512-514.

Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl 1989;230:1-54.

Bernard et al: Recognizing Specific Characteristics of Nonspecific Low Back Pain. Clin Orthop Relat Res. 1987 Apr;(217):266-80.

Birrell F, Croft P, Cooper C, et al. Predicting radiographic hip osteoarthritis from range of movement. Rheumatology (Oxford).2001 ;4 0:506–512

Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. J Bone Joint Surg Am 1990;72:403–8.

Bohl WR, Steffee AD. Lumbar spinal stenosis. A cause of continued pain and disability in patients after total hip arthroplast y. Spine 1979;4:168–73

Chen K, Nizar A.Prevalence of piriformis syndrome in chronic low back pain patients. A clinical diagnosis with modified FAIR test. Pain Pract. 2013 Apr;13(4):276-81.

Cher D, et al. Sacroiliac joint pain: burden of disease. Med Devices (Auckl). 2014;7:73-81.

Ciibulka MT, White DM, Woehrle J, Harris-Hayes M, Eneski K, Fagerson TL, Slover J, Godges JJ. Hip Pain and Mobility Deficits - Hip Osteoarthritis: Clinical Practice Guidelines Linked to the International
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iFuse Implant System – Bibliography

LEVEL I – Randomized Clinical Trial

Whang PG, Cher D, Polly D, Frank C, Lockstadt H, Glaser J, et al. Sacroiliac Joint Fusion Using Triangular Titanium Implants vs. Non-Surgical Management: Six-Month Outcomes from a Prospective Randomized Controlled Trial. Int J
Spine Surg. 2015;9:6.
Polly DW, Cher DJ, Wine KD, Whang PG, Frank CJ, Harvey CF, Lockstadt H, Glaser JA, Limoni RP, Sembrano JN, and the INSITE Study Group. Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion Using
Triangular Titanium Implants vs. Non-Surgical Management for Sacroiliac Joint Dysfunction: 12-Month Outcomes. Neurosurgery. 2015;77:674-91. [Epub ahead of print 2015 Aug 19] doi: 10.1227/NEU.0000000000000988.

LEVEL IIb – Prospective, Multicenter

Duhon BS, Cher DJ, Wine KD, Lockstadt H, Kovalsky D, Soo C-L. Safety and 6-month effectiveness of minimally invasive sacroiliac joint fusion: a prospective study. Med Devices (Auckl). 2013;6:219–29. doi:10.2147/MDER.S55197.

Heiney J, Capobianco R, Cher D. A Systematic Review of Minimally Invasive Sacroiliac Joint Fusion Utilizing A Lateral Transarticular Technique. Int J Spine Surg. 2015;9:Article 40. doi:10.14444/2040.

LEVEL III – Clinical Comparison (Open vs. MIS)

Graham Smith A, Capobianco R, Cher D, Rudolf L, Sachs D, Gundanna M, et al. Open versus minimally invasive sacroiliac joint fusion: a multi-center comparison of perioperative measures and clinical outcomes. Ann Surg Innov Res.
2013;7:14. doi:10.1186/1750-1164-7-14.
Ledonio CGT, Polly DW, Swiontkowski MF. Minimally Invasive Versus Open Sacroiliac Joint Fusion: Are They Similarly Safe and Effective? Clin Orthop Relat Res. 2014;472:1831–8.
Ledonio C, Polly D, Swiontkowski MF, Cummings J. Comparative effectiveness of open versus minimally invasive sacroiliac joint fusion. Med Devices (Auckl). 2014;2014:187–93.

LEVEL IV – Clinical
Vanaclocha VV, Verdú-López F, Sánchez-Pardo, M, Gozalbes-Esterelles L, Herrera JM, Rivera-Paz M, et al. Minimally Invasive Sacroiliac Joint Arthrodesis: Experience in a Prospective Series with 24 Patients. J Spine. 2014;3:185.
Rudolf L, Capobianco R. Five-Year Clinical and Radiographic Outcomes After Minimally Invasive Sacroiliac Joint Fusion Using Triangular Implants. Open Orthop J. 2014;8:375–83.
Sachs D, Capobianco R, Cher D, Holt T, Gundanna M, Graven T, et al. One-year outcomes after minimally invasive sacroiliac joint fusion with a series of triangular implants: a multicenter, patient-level analysis. Med Devices (Auckl).
2014;7:299–304.
Schroeder JE, Cunningham ME, Ross T, Boachie-Adjei O. Early Results of Sacro–Iliac Joint Fixation Following Long Fusion to the Sacrum in Adult Spine Deformity. Hosp Spec Surg J. 2013;10:30–5.
Gaetani P, Miotti D, Risso A, Bettaglio R, Bongetta D, Custodi V, et al. Percutaneous arthrodesis of sacro-iliac joint: a pilot study. J Neurosurg Sci. 2013;57:297–301.
Cummings J Jr, Capobianco RA. Minimally invasive sacroiliac joint fusion: one-year outcomes in 18 patients. Ann Surg Innov Res. 2013;7:12. doi:10.1186/1750-1164-7-12.
Sachs D, Capobianco R. Minimally invasive sacroiliac joint fusion: one-year outcomes in 40 patients. Adv Orthop. 2013;2013:536128.
Rudolf L. MIS Fusion of the SI Joint: Does Prior Lumbar Spinal Fusion Affect Patient Outcomes? Open Orthop J. 2013;7:163–8.
Sachs D, Capobianco R. One year successful outcomes for novel sacroiliac joint arthrodesis system. Ann Surg Innov Res. 2012;6:13.
Rudolf L. Sacroiliac Joint Arthrodesis-MIS Technique with Titanium Implants: Report of the First 50 Patients and Outcomes. Open Orthop J. 2012;6:495–502.

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References
iFuse Implant System – Bibliography (cont.)
Clinical – Other
Miller L, Reckling WC, Block JE. Analysis of postmarket complaints database for the iFuse SI Joint Fusion System: a minimally invasive treatment for degenerative sacroiliitis and sa croiliac joint disruption. Med
Devices (Auckl). 2013;6:77–84.
Woods M, Birkholz D, MacBarb R, Capobianco R, Woods A. Utility of Intraoperative Neuromonitoring during Minimally Invasive Fusion of the Sacroiliac Joint. Adv Orthop. 2014;2014:154041.

Biomechanics
Lindsey D, Perez-Orribo L, Rodriquez-Martinez N, Reyes P, Newcomb A, Cable A, et al. Evaluation of a minimally invasive procedure for sacroiliac joint fusion – an in vitro biomechanical analysis of initial and
cycled properties. Med Devices (Auckl). 2014;2014:131–7.
Soriano-Baron H, Lindsey DP, Rodriguez-Martinez N, Reyes PM, Newcomb A, Yerby SA, Crawford NR. The Effect of Implant Placement on Sacroiliac Joint Range of Motion: Posterior vs Trans-articular. Spine.
2015;40:E525-E530.

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