SENSITIVITY AND SPECIFICITY OF PHYSICAL EXAMINATION TESTS FOR SACROILIAC PAIN IN THE ADOLESCENT AND YOUNG ATHLETES

Pierre d’Hemecourt; Dai Sugimoto; Maxwell McKee-Proctor; Andrea Stracciolini

摘要

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. Table 1. 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 (%) Distraction 53.8 18.8 72.9 9.1 0.66 2.46 46.9 Thigh Thrust 84.8 5.9 77.8 9.1 0.90 2.58 68.7 Figure of Four 60.0 11.8 72.2 7.1 0.68 3.40 50.0 FABER 70.8 11.8 75.4 9.5 0..80 2.48 58.5 Lateral 60.0 17.6 73.6 10.3 0.73 2.27 51.2 Compression Sacral Torque 92.3 5.9 78.9 16.7 0.98 131 74.4 Sacral 80.0 5.9 76.5 7.1 0.85 3.40 64.6 Compression Gaenslen 42.9 35.3 71.1 14.3 0.66 1.62 41.3 Stinchfield 54.8 12.5 70.8 6.7 0.63 3.61 46.2

机译：背景：腰痛是年轻运动员的常见临床不适。 sa（SI）疼痛的诊断通常具有挑战性，因为许多非特定的体格检查发现对临床诊断都具有挑战性。先前的研究试图确定最准确的体格检查测试。然而，研究结果仅限于成人人群[1]。对于SI疼痛的小儿，青少年和年轻成人患者，尚未建立最准确的体格检查方法。因此，本研究的目的是确定SI体格检查测试的敏感性和特异性，以便更准确地诊断小儿，青少年和成年运动员的SI关节病理。方法：采用前瞻性研究设计。到运动医学诊所就诊的腰背痛的小儿，青少年和年轻人经历了一系列针对SI病理的身体检查。 SI的体格检查包括：1）骨盆撑开，2）大腿推力，3）四字形，4）屈伸-外转（FABER），5）骨盆压迫，6）s骨扭矩，7）ac骨压迫，8）Gaenslen的测试和9）Stinchfield的测试。每次测试后，所有研究患者均以0到100的视觉模拟量表（VAS）自我报告疼痛水平。然后，对所有研究患者进行超声引导下将麻醉剂和皮质类固醇注射到SI关节中进行治疗。为了评估9个激发试验中每一个的准确性，通过在SI注射之前对SI特殊激发试验的正面（+）或负面（-）反应，以及（+）或（- ）SI注射后对麻醉剂和皮质类固醇的反应。那些在注射后立即显示出50％或更大的疼痛缓解率的人被诊断为SI病理，因此反应为（+）。根据2 x 2列联表，计算出每个激发试验的敏感性，特异性，阳性和阴性预测值，阳性和阴性可能性比以及准确性。结果：共测试了69名参与者（年龄：19.5±5.5岁，年龄范围：13-52，性别：11位男性和58位女性）。有14名参与者有双侧SI症状的主诉。因此，左右分别进行了处理，总共得到83个数据点。表1总结了每个激发测试的结果。在诊断SI关节病理方面，骨扭矩操作被认为是最敏感的（92.3％）和最准确的（74.4％）。除Gaenslen测试外，所有操作的灵敏度均超过50％。但是，分心，Gaenslen和Stinchfield动作的准确性低于50％。结论/意义：在儿科，青少年和年轻人群中，重现sa关节疼痛的三个最敏感的临床激发试验是leading骨扭矩，大腿推力和骨压缩试验。这三个测试还证明了相对较高的准确性（＞ 60％）。这些发现支持所选体格检查测试的临床实用性，以准确诊断SI关节病变。由于假阳性和假阴性的数量相对较高，很明显，有必要进行更多的研究以优化这些操作，然后再将其视为独立的临床工具。但是，这些结果的含义令人鼓舞，并且有理由更详细地探讨SI关节挑衅性动作的实用性。表1.详细列出了九种挑衅性动作对SI关节病理的预测能力的统计数据。操纵灵敏度（％）特异性（％）正预测值（％）负预测值（％）正似然比负似然比准确性（％）分心53.8 18.8 72.9 9.1 0.66 2.46 46.9大腿推力84.8 5.9 77.8 9.1 0.90 2.58 68.7四个60.0 11.8 72.2 7.1 0.68 3.40 50.0纤维70.8 11.8 75.4 9.5 0..80 2.48 58.5横向60.0 17.6 73.6 10.3 0.73 2.27 51.2 S骨扭矩压缩92.3 5.9 78.9 16.7 0.98 131 74.4 ac骨80.0 5.9 76.5 7.1 0.85 3.40 64.6压缩4骨42.9 35.3 14.3 0.66 1.62 41.3 Stinchfield 54.8 12.5 70.8 6.7 0.63 3.61 46.2

SENSITIVITY AND SPECIFICITY OF PHYSICAL EXAMINATION TESTS FOR SACROILIAC PAIN IN THE ADOLESCENT AND YOUNG ATHLETES

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