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De Vries HJ, MSc Vleeming A, PhD Ronchetti I, MSc van Wingerden JP, BSc Spine & Joint Centre, the Netherlands
1. There is a need for reliable clinical tests for the pelvic
joints to diagnose pelvic girdle pain (PGP).
2. In subjects with PGP the ilium is rotated anterior
relative to the sacrum during load transfer. BKC
3. Manual tests to detect an anterior rotation of the
ilium relative to the sacrum are not reliable. DKEKF
4. An anterior rotation of the ilium relative to the
sacrum increases tension in the long dorsal sacroiliac
The last decade saw increasing efforts among
clinicians and researchers to study pain and the
etiology of pelvic girdle pain (PGP). The prevalence of
pregnant women suffering from PGP is close to 20%.
The pain or functional disturbances in relation to PGP
must be reproducible by speciﬁc clinical tests.
One of the structures near the SI-joint that could easy
be overloaded is the long dorsal sacroiliac ligament
(LDL), which has been described anatomically and
functionally by Vleeming et al. as a mechanical
counter-nutational strain of the LDL (ﬁgure 1). G
According to Willard et al., anatomically the
neurovascular bundles of the lateral branches
of the dorsal sacral rami lie between ‘numerous,
discontinuous interwoven bands of dense connective
tissue’ over the posterior sacral surface. On this
basis it has been suggested that a potential for pain
generation exists. J
McGrath et al. investigated the anatomy/morphology
of the LDL. Their morphological ﬁndings offer “a
potential patho-anatomical mechanism that may
explain the identiﬁcation of localized pain in the
sacroiliac region, usually interpreted as referred pain
from the sacroiliac joint. The lateral branches of the
dorsal sacral rami appear vulnerable to trauma or
ischaemic challenge. This may account for sacroiliac
joint related ‘non-speciﬁc’ low back pain or for
pregnancy related PGP”. BA
A cross-sectional analysis was performed in a group
of patients with pelvic girdle pain after pregnancy. A
total of 254 patients with PGP after pregnancy were
selected from the outpatient clinic of a rehabilitation
centre, specialized in the treatment of lumbopelvic
pain; 44 control subjects were used. Pain in the LDL
was detected by standardized palpation of this
ligament (ﬁgure 2) by speciﬁcally trained physicians
and physiotherapists, and scored on a modiﬁed
4-point pain scale (no
pain = 0; mild pain = 1;
moderate pain = 2;
severe pain = 3).
It is important that
palpation is strictly
between the boundaries
of the ligament, and
not confused at the
medial side with the m.
multiﬁdus and at the
lateral side with the
attachment of the m.
gluteus maximus. The
LDL test score relied on
the patients statements
of pain or tenderness at
Table 1 shows the data on the sensitivity of the LDL
test in 254 patients with PGP and the speciﬁcity of the
LDL test in 44 healthy controls.
Sensitivity of the LDL test
In the patients, 232 indicated pain on palpation of
the LDL (sensitivity = 91%). The LDL test was scored
positive with a unilateral score ≥ 1. When the LDL
test was assessed positive with a unilateral score ≥ 2,
202 patients indicated pain on palpation of the LDL
(sensitivity = 80%).
Speciﬁcity of the LDL test
In the group of 44 controls the speciﬁcity of the LDL
test is 61% when the test was assessed positive with
a unilateral score ≥ 1. When the LDL test was assessed
positive with a unilateral score ≥ 2, the speciﬁcity is
Table 2: Long dorsal sacroiliac ligament (LDL) test scores of 254 patients
with pelvic girdle pain (PGP) after pregnancy and 44 healthy controls.
Table 2 shows the precise scores on the LDL test in the
patients group and the control group.
LDL test score
left - right side
Number of patients Number of controls
0 - 0 22 (9%) 27 (61%)
0 - 1 6 1
1 - 0 9 10
1 - 1 15 4
0 - 2 8
2 - 0 5
0 - 3 4
3 - 0 1
1 - 2 19 1
2 - 1 29 1
2 - 2 37
1 - 3 3
3 - 1 4
2 - 3 25
3 - 2 19
3 - 3 48
Total 254 44
LDL test score
¹ 1 232 / 254 = 91% 27 / 44 = 61%
≥ 2 202 / 254 = 80% 42 / 44 = 96%
≥ 3 104 / 254 = 41% 44 / 44 = 100%
Table 1: Sensitivity of the long dorsal sacroiliac ligament (LDL) test in 254
patients with pelvic girdle pain (PGP) after pregnancy and speciﬁcity in 44
ligament (LDL). G
5. Palpation of the LDL is painful in patients with
pelvic girdle pain. HKI
6. The LDL can be a nociceptive source of pain in the
sacroiliac region. JKBA
7. Pain after palpation of the LDL is an indicator for
an anterior rotation of the ilium relative to the
sacrum, and has consequences for therapy.
8. Palpation of the LDL is not painful in a group of
Purpose of this study
9. At this time no studies are available on the
speciﬁcity of the LDL test. This study determines the
sensitivity and speciﬁcity of the LDL test in a group
of patients and healthy controls.
• Although the LDL is a superﬁcially located
structure, experience shows that adequate
training in anatomy in vivo of this area is a
necessity to properly locate the ligament.
• Literature is not uniform about intertester
agreement for the LDL test, Kappa ranges from
0.34 H to 0.76.
• In some healthy subjects palpation of the LDL was
painful (table 2). It is not clear why these subjects
do not experience pain in daily life.
• In an earlier study, the LDL test was scored positive
(pain) or negative (no pain). I The speciﬁcity of the
test was not determined in that study. Unknown
is what the speciﬁcity of the LDL test is when a
2-points (positive or negative) instead of a 4-points
scale is used.
The long dorsal sacroiliac ligament test has a high
sensitivity and speciﬁcity when a unilateral cut-off
score ≥ 2 is used. Patients have to indicate at least
moderate or severe pain.
You can ﬁnd the complete text of this study in the congress book.
Ref erenc es
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determined in subjects with posterior pelvic pain using skin markers. Clin
Biomech (Bristol, Avon) 2004; 19: 456-64.
3. Kristiansson P, Svärdsudd K. Discriminatory power of tests applied in back
pain during pregnancy. Spine 1996; 20:2337-2344.
4. Laslett M, Williams M. The reliability of selected pain PPPP tests for
sacroiliac joint pathology. Spine 1994; 19:1243-9.
5. Wormslev M, Juul AM, Marques B, et al. Clinical examination of pelvic
insufﬁciency during pregnancy. Scand J Rheumatol 1994; 23:96-102.
6. Vleeming A, Pool-Goudzwaard AL, Hammudoglu D, et al. The function of
the long dorsal sacroiliac ligament. Spine 1996; 21:562-565.
7. Albert H, Godskesen M, Westergaard J. Evaluation of clinical tests used in
classiﬁcation procedures in pregnancy-related pelvic joint pain. Eur Spine
J 2000; 9:161-166.
8. Vleeming A, Vries de HJ, Mens JMA, et al. The possible role of the long
dorsal ligament in peripartum pelvic pain. Acta Obstet Gynecol Scand
9. Willard FH, Carreiro JE, Manko W. The long posteriori interosseous
ligament and the sacrococcygeal plexus. In: Third interdisciplinary world
congress on low back and pelvic pain, Vienna.
10. McGrath MC, Zhang M. Lateral branches of dorsal sacral nerve plexus and
the long posterior sacroiliac ligament. Surg Radiol Anat 2005; 27:327-330.
Spine Joint Centre
Pelvic girdle pain:
the sensitivity and speciﬁcity of the
Long Dorsal Sacroiliac Ligament test