Goldthwait’s sign is a clinical maneuver used to differentiate pain arising from the sacroiliac (SI) joint from pain due to the lumbosacral spine. Pain elicited during specific leg-raising and palpation maneuvers suggests irritation or pathology in the SI joint or lumbosacral articulation.

Pathophysiology

• Sacral and lumbar structures share nerve roots and biomechanical connections.

• Pain referral patterns can overlap, making it challenging to distinguish SI joint from lumbosacral pathology.

• The test relies on timing and localization of pain during passive leg elevation to differentiate:

  • Early pain during leg raise with hand under lumbar region → likely SI joint irritation

  • Pain after lumbar pressure applied → likely lumbosacral joint involvement

Examination Technique

1. Patient positioning: Place the patient in a supine position on a flat examination table.

2. Hand placement:

   • Place one hand under the small of the back to monitor lumbar movement.

3. Leg raise:

   • With your other hand, raise the patient’s leg slowly, keeping the knee extended.

   • Ask the patient to report any pain and note the location.

4. Interpretation:

   • Pain during leg raise with hand under lumbar spine: Suggests sacroiliac joint irritation.

   • No pain initially, but pain when pressure applied under lumbar spine: Suggests lumbosacral or sacroiliac articulation irritation.

5. Documentation: Record side, intensity, and precise location of pain.

Clinical Features

Differential Diagnosis

Pediatric considerations

• Rarely used in children unless trauma or congenital SI anomalies are suspected.

• Technique must be gentle to avoid discomfort or injury.

Geriatric considerations

• SI joint degeneration, osteoarthritis, or lumbar spondylosis may affect interpretation.

• Take care with osteoporotic patients to avoid fractures during leg raising.

Limitations

• Pain perception is subjective and may vary between patients.

• Not definitive alone; should be combined with imaging (X-ray, MRI) and other orthopedic tests.

• Muscle tightness or hamstring spasm may give false-positive pain.

Patient counseling

• Explain that the test helps identify the source of lower back or buttock pain.

• Advise gentle movement and relaxation during the exam.

• Highlight the importance of follow-up evaluation for persistent or severe pain.

Conclusion

Goldthwait’s sign is a practical clinical maneuver to help distinguish sacroiliac joint irritation from lumbosacral pathology. Proper technique, careful observation, and correlation with imaging and clinical context improve diagnostic accuracy and guide targeted management.

References

1. Goldthwait JE. The diagnostic significance of the lumbosacral and sacroiliac joints in low back pain. Boston Med Surg J. 1911;164:101–104.

2. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344:363–370.

3. Magee DJ. Orthopedic Physical Assessment. 6th ed. Philadelphia: Elsevier; 2014.

4. Ropper AH, Samuels MA. Adams and Victor’s Principles of Neurology. 11th ed. New York: McGraw-Hill; 2021.