Posterior Pelvic Pain Provocation Test

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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


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.


The gold standard to evaluate sacroiliac pain provocation tests is an intra-articular injection of a local anesthetic 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 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: [8][9][10][11][5][8]

Laslett et al (2005) state that no further examination is wishful if both distraction and thigh thrust test provoke 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.[11] 

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%.[12][8][11][8][5] [13]


  1. JK Freburger, DL Riddle. Using published evidence to guide the examination of the sacroiliac joint region. Phys Ther. 2001; 81:1135–1143
  2. Laslett M, April CN, McDonald B, Young SB. Diagnosing Painful SI joints: A validation study of Mckenzie and SI provocation tests. Aust J Physiotherapy. 2003; 49:89-97.
  3. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of SI joint pain: validity of individual provocation test and composites of tests. Manual Therapy 2005; 10:207-218.
  4. P Vercellini. Chronic pelvic pain. Wiley-Blackwell 2011: 118-119
  5. 5.0 5.1 5.2 NA Broadhurst, MJ Bond. Pain provocation tests for the assessment of sacroiliac joint dysfunction. J Spine Disorders. 1998; 11(4):341–345
  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 test for sacroiliac joint pathology. Spine 1998; 19(11): 1243-1249
  8. 8.0 8.1 8.2 8.3 KJ Stuber. Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature. J Can Chiropr Assoc. 2007; 51(1): 30-41
  9. BA Zelle, GS Gruen, S Brown, S George. Sacroiliac dysfunction: evolution and management. Clin J Pain. 2005; 21(5):446-455
  10. JK Freburger, DL Riddle. Using Published Evidence to Guide the Examination of the Sacroiliac Joint Region. Physical Therapy. 2001; 81(5):1135-1143
  11. 11.0 11.1 11.2 M Laslett et al. Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Manual Therapy 2005; 10:207-218
  12. CC Yung, M Fredericson, M Smuck. Sacroiliac Joint Pain Syndrome in Active Patients - A Look Behind the Pain. The Physician and Sports Medicine 2002; 30(11)
  13. Mousaui SJ, Mousaui L, Alavizadeli A, Kamal S. Jrnl of Research in Rehabilitation Sciences; Vol 3, No.1(86).