Osteopathic Standing Flexion Test Interpretation
The somatic dysfunction is located on the RIGHT side (ipsilateral to the raised PSIS), and the patient's left hip pain radiating to the left knee likely represents referred pain from the right-sided sacroiliac dysfunction or indicates a separate pathology requiring imaging workup.
Understanding the Standing Flexion Test
In osteopathic structural examination, the standing flexion test (also called the standing forward bend test) evaluates sacroiliac joint motion by monitoring PSIS movement during forward bending 1, 2:
- Normal finding: Both PSISs should move symmetrically and equally during forward flexion 1
- Abnormal finding: The PSIS that rises MORE or EARLIER indicates restricted motion on that side 1, 2
- Interpretation: The side with the raised PSIS is the side of somatic dysfunction (restricted sacroiliac joint motion) 2, 3
In this case, the RIGHT PSIS rises during forward bending, indicating RIGHT-sided sacroiliac somatic dysfunction 1, 2.
Clinical Significance of Left-Sided Pain with Right-Sided Dysfunction
The discordance between the examination finding (right-sided dysfunction) and symptom location (left hip/knee pain) requires careful consideration:
Possible Explanations:
- Compensatory patterns: Right sacroiliac restriction may cause compensatory stress on the left hip, leading to left-sided symptoms 2
- Separate pathology: The left hip pain may represent a distinct intra-articular or extra-articular hip problem unrelated to the right sacroiliac dysfunction 4
- Referred pain patterns: Sacroiliac dysfunction can produce complex referred pain patterns, though typically ipsilateral 4, 2
Recommended Diagnostic Approach
Given the left hip pain radiating to the knee, imaging is essential to rule out significant hip pathology 5, 6:
Initial Imaging:
- Obtain AP pelvis and frog-leg lateral hip radiographs immediately to evaluate for osteoarthritis, fractures, avascular necrosis, or bone abnormalities 5, 6
- Radiographs should include bilateral views to compare both hips 5
Advanced Imaging if Radiographs Are Negative or Equivocal:
- MRI hip without IV contrast is the next appropriate test for detecting occult fractures, osteonecrosis, labral tears, soft tissue pathology, or referred pain from lumbar spine 5, 6, 4
- MRI can evaluate extra-articular causes including trochanteric bursitis, gluteus medius tendinopathy, iliopsoas bursitis, and hamstring injuries 5, 4
Diagnostic Injection:
- Ultrasound or fluoroscopy-guided intra-articular hip injection with anesthetic can confirm whether pain originates from the hip joint itself 5, 6
Critical Pitfalls to Avoid
- Do not assume the left hip pain is solely from right sacroiliac dysfunction without imaging 5, 6, 4
- Do not delay imaging in patients with persistent hip pain, as conditions like avascular necrosis, occult fractures, or labral tears require early diagnosis for optimal outcomes 5, 6, 4
- Recognize that somatic dysfunction diagnosis has fair-to-poor interrater reliability (κ=0.17-0.34 for TART parameters), so clinical correlation with imaging is essential 1
- Consider lumbar spine pathology as a source of referred hip and knee pain, particularly if neurologic symptoms are present 5, 4
Treatment Considerations
While osteopathic manipulative treatment may address the right sacroiliac dysfunction 2, the left hip pain requires:
- Definitive diagnosis through imaging before initiating treatment 5, 6, 4
- Evaluation for intra-articular pathology (labral tears, femoroacetabular impingement, osteoarthritis) which may benefit from surgical intervention 5, 4
- Assessment of extra-articular causes (greater trochanteric pain syndrome, gluteus medius tears) which have specific treatment protocols 5, 4