Posterior Pelvic Pain Provocation Test

Purpose[edit | edit source]

The posterior pelvic pain provocation test is a pain provocation test used to determine the presence of sacroiliac dysfunction. It is used (often in pregnant women) to distinguish between pelvic girdle pain and low back pain.[1] [2][3]

The test is also known as:

  • PPPP test
  • P4 test
  • Thigh thrust test
  • Posterior shear test
  • POSH test

Technique[edit | edit source]

With the patient supine, the hip is flexed to 90° (with bended knee) to stretch the posterior structures. By applying axial pressure along the length of the femur, the femur is used as a lever to push the ilium posteriorly. One hand is placed beneath the sacrum to fixate its position while the other hand is used to apply a downward force to the femur. Broadhurst and Bond suggest to add hip adduction towards the midline while Laslett & Williams advise to avoid excessive adduction due to discomfort for the patient. [4][5][6][7]

The test is positive for pelvic girdle pain if the axial pressure provokes pain over the sacroiliac joint that is familiar to the patient.



Evidence[edit | edit source]

The gold standard to evaluate sacroiliac pain provocation tests is an intra-articular injection of a local anaesthetic into the sacroiliac joint, under the guidance of radiological imaging. Several studies have compared existing pain provocation tests and concluded that not a single test but a cluster of tests should be used to confirm the diagnosis (grade A recommendation). There is level 1A evidence stating that a combination of positive tests (2 out of 4, 3 out of 5,…) produces a high likelihood ratio. Most commonly used tests with both sensitivity and specificity greater than 60% are: [10][11][12][13][5][10]

Laslett et al (2005) state that no further examination is wishful if both distraction and thigh thrust test provokes familiar pain because of their high individual sensitivity and specificity. If only one test or 2 other tests are positive, further testing is required to obtain a valid result.[13] 

The posterior pelvic pain provocation test has a high intertester reliability of 94,1 (kappa=0,64-0,82 and p<0,001) and a high degree of sensitivity (80-88%) and specificity (100%) in 2 studies of moderate to high methodological quality. Positive predictive value ranges from 25% to 70% and negative predictive value goes from 88% to 92%.[14][10][13][10][5] [15]

References[edit | edit source]

  1. Freburger JK, Riddle DL. Using published evidence to guide the examination of the sacroiliac joint region. Physical therapy. 2001 May 1;81(5):1135-43.
  2. Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy. 2003 Jan 1;49(2):89-97.
  3. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual therapy. 2005 Aug 1;10(3):207-18.
  4. P Vercellini. Chronic pelvic pain. Wiley-Blackwell 2011: 118-119
  5. 5.0 5.1 5.2 Broadhurst NA, Bond MJ. Pain provocation tests for the assessment of sacroiliac joint dysfunction. Journal of spinal disorders. 1998 Aug;11(4):341-5.
  6. M Laslett. Pain provocation sacroiliac joint tests: reliability and prevalence. In: Vleeming A, Mooney V, Snijders CJ, Dormann TA, Stoeckart R, editors. Movement, Stability and Low Back Pain: The Essential Role of the Pelvis. 1st ed. New York: Churchill Livingstone; 1997
  7. Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine. 1994 Jun;19(11):1243-9.
  8. Mattptnation. The Thigh Thrust Test. Available from: [last accessed 25/10/2020]
  9. Wchaffe. The Thigh Thrust Test. Available from: [last accessed 25/10/2020]
  10. 10.0 10.1 10.2 10.3 Stuber KJ. Sspecificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature. The Journal of the Canadian Chiropractic Association. 2007 Mar;51(1):30.
  11. BA Zelle, GS Gruen, S Brown, S George. Sacroiliac dysfunction: evolution and management. Clin J Pain. 2005; 21(5):446-455
  12. JK Freburger, DL Riddle. Using Published Evidence to Guide the Examination of the Sacroiliac Joint Region. Physical Therapy. 2001; 81(5):1135-1143
  13. 13.0 13.1 13.2 Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual therapy. 2005 Aug 1;10(3):207-18.
  14. Chen YC, Fredericson M, Smuck M. Sacroiliac joint pain syndrome in active patients: a look behind the pain. The Physician and sportsmedicine. 2002 Nov 1;30(11):30-7.
  15. Mousaui SJ, Mousaui L, Alavizadeli A, Kamal S. Jrnl of Research in Rehabilitation Sciences; Vol 3, No.1(86).