1. Sacrum screening
   • Key differential diagnoses
   • Subjective history and pain behavior
   • Sacral red flags
   • System-wise past medical history and review of systems
   • Clinical presentation, associated symptoms, examination priorities, and referral actions
2. Sacroiliac joint screening
   • Mechanical SIJ presentation versus non-musculoskeletal mimics
   • Inflammatory sacroiliitis / spondyloarthritis screen
   • Pregnancy and postpartum considerations
   • Red flags, systems review, and referral decisions
3. Pelvic screening
   • Hip, lumbar, pelvic-floor, genitourinary, gastrointestinal, gynecologic, vascular, neurologic, and malignancy-related sources
   • Sex-specific and age-related considerations
   • Red flags, review of systems, and referral pathways
4. Simplified Goodman and Snyder screening framework
   • Stepwise subjective screen
   • Risk-factor screen
   • Symptom-behavior analysis
   • Systems review
   • Objective examination precautions
   • Urgent versus routine medical referral
5. Quick physiotherapy documentation templates
   • Past medical history checklist
   • Red-flag checklist
   • Review-of-systems checklist
   • Referral note format

Sacrum Screening: Simplified Physiotherapy Notes

Goodman and Snyder Screening Model for Referral

Scope: These notes focus on sacral-region symptoms, not sacroiliac joint dysfunction. The sacrum is screened as a possible site of fracture, tumour, infection, neurologic compromise, inflammatory disease, or referred visceral pain before assigning a mechanical diagnosis. This is an original study summary using the Goodman and Snyder medical-screening approach, not a reproduction of the textbook.

1. Why Screen the Sacrum?

• Sacral stress or insufficiency fracture
• Traumatic sacral fracture
• Metastatic disease, primary bone tumour, or sacral chordoma
• Infection, including osteomyelitis, discitis, epidural abscess, or septic sacroiliac disease
• Cauda equina or conus medullaris compression
• Lumbar radiculopathy or sacral nerve-root lesion
• Inflammatory spondyloarthritis
• Gynecologic, gastrointestinal, urologic, or vascular referral
• Coccygodynia or pelvic-floor disorder

2. Goodman and Snyder Style Screening Sequence

1. Identify the symptom location and behavior
2. Screen past medical history and risk factors
3. Ask red-flag questions
4. Perform a system-by-system review
5. Compare subjective history with objective findings
6. Determine whether the presentation is mechanical, non-mechanical, or mixed
7. Choose action
   • Treat and monitor
   • Treat with medical co-management
   • Routine medical referral
   • Urgent same-day medical referral
   • Emergency referral

3. First Question: Is This Likely Mechanical Sacral Pain?

A. Features more consistent with a mechanical musculoskeletal presentation

• Clear relation to a movement, posture, load, impact, fall, prolonged sitting, or altered activity
• Pain reproduced consistently by a specific movement or task
• Symptoms ease with unloading, positional change, or modification of aggravating activity
• Local tenderness or pain with loading that matches the history
• Improvement over time with appropriate activity modification
• No systemic symptoms, major trauma, neurologic deterioration, or major risk factors

• Pain after a direct fall onto the buttocks
• Pain after a large sudden increase in running, marching, jumping, or walking volume
• Local tailbone pain provoked primarily by sitting
• Sacral pain associated with a clear overload history, provided fracture risk has been considered

B. Features that make a purely mechanical explanation less likely

• Constant, progressive, severe, or disproportionate
• Unrelated to movement, position, or loading
• Present at rest and not eased by repositioning
• Markedly worse at night or repeatedly wakes the patient
• Associated with fever, chills, fatigue, weight loss, cancer history, infection risk, neurologic symptoms, or visceral symptoms
• Not improving as expected despite appropriate conservative care
• Associated with new gait disturbance, bilateral leg symptoms, saddle sensory change, or altered bladder/bowel/sexual function

4. Subjective Examination: Key Questions

A. Location and distribution

• “Point with one finger to the worst pain.”
• “Is the pain central over the sacrum, one-sided, near the tailbone, in the buttock, groin, perineum, or down the leg?”
• “Does pain spread below the knee?”
• “Do you have pain in the rectal, genital, perineal, abdominal, pelvic, or groin area?”

Clinical interpretation

B. Symptom behavior

• When did symptoms start?
• Was onset sudden, gradual, or without a clear cause?
• What happened before onset: fall, trauma, childbirth, major training change, infection, surgery, cancer treatment, prolonged immobilization?
• Is pain affected by walking, stairs, rolling in bed, sitting, coughing, sneezing, bowel movement, urination, or sexual activity?
• Is pain relieved by rest, changing position, medication, or unloading?
• Is pain constant?
• Does pain wake you? If yes, does changing position relieve it?
• Is the pain getting progressively worse?

Important symptom patterns

Possible sacral stress or insufficiency fracture

• New deep sacral, buttock, groin, or low-back pain
• Pain with weight-bearing, walking, standing, stairs, transfers, or single-leg loading
• May have no major trauma
• Often progressive over days or weeks
• May have focal sacral tenderness
• High suspicion in older adults, patients with osteoporosis, those on prolonged corticosteroids, after pelvic radiation, or endurance athletes with abrupt training change

Possible cancer or tumour

• Previous or current cancer
• Increasing, unremitting pain
• Symptoms unrelated to ordinary mechanical loading
• Pain at rest or night pain, especially when combined with other findings
• Unexplained weight loss, anorexia, unusual fatigue, malaise
• Failure to improve or a worsening pattern

Possible infection

• Severe localized pain and tenderness
• Fever, chills, sweats, malaise
• Recent infection, wound, skin infection, urinary infection, or invasive procedure
• Immunosuppression, diabetes, intravenous drug use, dialysis, recent spinal/pelvic procedure
• Pain that appears disproportionate or rapidly worsening

Possible neurologic emergency

• Bilateral sciatica or bilateral leg symptoms
• New or progressive weakness
• Numbness in saddle/perineal region
• New urinary retention, overflow incontinence, loss of urinary sensation, or marked change in bowel control
• New sexual dysfunction associated with neurologic symptoms

5. Past Medical History Screening

A. Cancer history

• Any current or previous cancer
• Breast, prostate, lung, kidney, thyroid, multiple myeloma, lymphoma, colorectal, gynecologic, or other malignancy
• Bone metastases
• Radiation therapy to the pelvis or spine
• Chemotherapy, hormonal therapy, immunotherapy, or long-term steroid use
• Recent imaging, oncology follow-up, or unexplained abnormal blood tests

Why it matters

B. Bone health and fracture-risk history

• Osteoporosis or osteopenia
• Previous fragility fracture
• Age-related fracture risk
• Recent fall, direct buttock trauma, motor vehicle accident, or high-energy trauma
• Prolonged corticosteroid use
• Rheumatoid arthritis or inflammatory disease
• Eating disorder, low body weight, malnutrition, vitamin D deficiency
• Menstrual irregularity, amenorrhea, low energy availability, relative energy deficiency in sport
• Pregnancy, postpartum period, lactation-associated bone loss
• Pelvic radiation
• Endocrine disease: hyperthyroidism, hyperparathyroidism, hypogonadism
• Renal disease, liver disease, malabsorption, coeliac disease
• Anticoagulant use, especially after trauma

Clinical clues for sacral insufficiency fracture

C. Infection-risk history

• Recent fever, chills, night sweats, or unexplained malaise?
• Recent skin, dental, urinary, respiratory, abdominal, or pelvic infection?
• Recent surgery, injection, spinal procedure, catheter, or invasive procedure?
• Diabetes?
• HIV or other immunocompromise?
• Use of corticosteroids, biologic drugs, chemotherapy, or transplant medication?
• Intravenous drug use?
• Tuberculosis exposure or previous TB?
• Recent severe bacterial infection or bacteremia?

D. Neurologic and spinal history

• Previous lumbar disc prolapse, spinal stenosis, spinal surgery, tumour, epidural injection, trauma, or infection
• Previous episodes of numbness, weakness, urinary retention, or bowel dysfunction
• Diabetes or peripheral neuropathy
• Multiple sclerosis, Parkinson disease, stroke, spinal cord injury, or other neurologic disorders
• New gait change, falls, foot drop, or reduced balance

E. Rheumatologic and inflammatory history

• Ankylosing spondylitis or axial spondyloarthritis
• Psoriasis
• Uveitis or painful red eye
• Inflammatory bowel disease
• Reactive arthritis
• Family history of spondyloarthritis
• Rheumatoid arthritis
• Morning stiffness lasting longer than 30 minutes
• Alternating buttock pain
• Improvement with movement but not rest
• Night pain that improves on getting up and moving

F. Medication history

• Corticosteroids
• Anticoagulants or antiplatelet drugs
• Cancer medications
• Immunosuppressive or biologic medication
• Osteoporosis medication
• Long-term opioids or recent medication changes
• Antibiotics for current/recent infection
• Hormonal therapy

6. Red-Flag Assessment for Sacral Pain

A. Emergency red flags: immediate emergency referral

• Urinary retention, inability to start urination, loss of urinary sensation, or overflow incontinence
• New fecal incontinence or loss of bowel control
• Saddle anesthesia or numbness around the anus, genitals, perineum, or inner thighs
• New bilateral leg weakness, progressive neurologic deficit, or bilateral severe sciatica
• Major gait loss related to neurologic weakness
• New sexual dysfunction with sacral neurologic symptoms
• Rapidly developing symptoms after major trauma

Important clarification

• Urinary sensation
• Ability to initiate urine flow
• Incomplete emptying
• Perineal sensation during wiping
• Changes during bowel movement
• New erectile, orgasmic, or genital sensory change

B. Urgent same-day referral red flags

Possible fracture

• Significant trauma
• Minor trauma in a person with known osteoporosis or high fracture risk
• Sudden severe pain with inability to weight-bear
• New progressive pain during walking or transfers in an older adult
• Severe focal sacral tenderness with fracture-risk factors

Possible infection

• Fever, chills, sweats, malaise with focal spinal/sacral pain
• Immunosuppression plus severe pain
• Recent infection or invasive procedure plus new sacral pain
• Intravenous drug use plus spinal/sacral pain
• Rapid worsening despite rest

Possible cancer

• Known malignancy plus new sacral pain
• Progressive, unremitting pain with constitutional symptoms
• Unexplained weight loss or persistent fatigue
• Pain that is worsening and not behaving mechanically
• New neurologic signs with cancer history

Possible vascular or hemorrhagic problem

• Severe sudden pain after trauma in someone using anticoagulants
• Syncope, hypotension, severe abdominal/pelvic pain, or signs of shock
• Severe pain with a pulsatile abdominal mass or known abdominal aortic aneurysm risk

C. Routine but prompt referral

• Persistent non-mechanical sacral pain
• No meaningful improvement after an expected conservative trial
• Suspected inflammatory back pain
• Unexplained recurrent sacral pain
• Suspected pelvic, gynecologic, gastrointestinal, urinary, or urologic referral
• New neurologic symptoms that are mild and stable but unexplained
• Pain with unexplained fatigue, anemia, appetite change, or systemic illness

7. Review of Systems: Sacral Pain

A. Constitutional system

• Fever
• Chills
• Night sweats
• Unexplained weight loss
• Loss of appetite
• Unusual fatigue
• General malaise
• Recent severe illness

Significance

B. Neurologic system

• Numbness, tingling, burning, electric pain?
• Weakness in one or both legs?
• Foot drop, tripping, difficulty heel walking or toe walking?
• Altered balance or falls?
• Bilateral leg symptoms?
• Perineal, genital, anal, or inner-thigh numbness?
• New bowel, bladder, or sexual change?
• Severe headache, new upper motor neuron symptoms, or widespread sensory symptoms?

Objective priorities

• Myotomal strength
• Sensory examination
• Reflexes
• Gait
• Heel/toe walking
• Neural provocation where safe
• Perianal/saddle symptom inquiry and urgent referral as indicated

C. Musculoskeletal system

• Recent trauma or fall?
• New exercise, running, jumping, marching, or loading program?
• Osteoporosis or previous fracture?
• Pain with weight-bearing?
• Inability to walk normally?
• Widespread joint pain, swelling, stiffness, or morning stiffness?
• History of inflammatory arthritis?

Interpretation

• Focal sacral tenderness plus bone-risk factors: consider fracture.
• Widespread joint symptoms plus prolonged morning stiffness: consider inflammatory/rheumatologic disease.
• Pain provoked only by a reproducible mechanical task, with no red flags: supports but does not prove a mechanical disorder.

D. Cardiovascular and vascular system

• Known vascular disease?
• Abdominal aortic aneurysm?
• New abdominal, groin, or flank pain?
• Dizziness, syncope, fainting?
• Calf swelling, redness, warmth, or sudden shortness of breath?
• Leg claudication, cold limbs, color changes?

Significance

E. Pulmonary system

• Shortness of breath?
• Persistent cough?
• Coughing blood?
• Chest pain?
• Recent pulmonary infection?
• Smoking history?
• Previous lung cancer?

F. Gastrointestinal system

• Abdominal pain, bloating, nausea, vomiting?
• Altered bowel habit?
• Constipation, diarrhea, blood in stool, black stool?
• Pain related to meals or defecation?
• Rectal pain or bleeding?
• Inflammatory bowel disease?
• Unexplained anemia or weight loss?

Clinical relevance

G. Genitourinary system

• Urinary frequency, urgency, dysuria, hematuria?
• Difficulty starting urination?
• Urinary retention or incomplete emptying?
• Incontinence?
• Flank pain?
• Recurrent urinary infection?
• Kidney stone history?
• Prostate disease or prostate cancer history?

Distinguish carefully

H. Reproductive and gynecologic system

• Pregnancy or postpartum status?
• Menstrual change, pelvic pain, dysmenorrhea, abnormal bleeding?
• Pain with intercourse?
• Endometriosis, fibroids, ovarian cysts, pelvic inflammatory disease?
• Previous gynecologic or pelvic cancer?
• Testicular pain, swelling, or male pelvic symptoms?

Significance

I. Integumentary system

• Recent skin wound, ulcer, cellulitis, pressure injury, rash, shingles
• Surgical wound or injection site
• Pilonidal sinus/cyst near the natal cleft
• New mass, drainage, redness, warmth, or swelling

8. Clinical Presentations That Need Differential Screening

1. Sacral stress fracture

Typical presentation

• Gradual deep sacral or buttock pain
• Training error, increased impact activity, military training, running, jumping, or reduced recovery
• Pain increases with loading and may progress to pain with walking
• May have local tenderness
• May not have obvious trauma

Risk factors

• Sudden training increase
• Low energy availability
• Menstrual disturbance/amenorrhea
• Previous stress fracture
• Low bone density
• Nutritional deficiency
• Female athlete triad/relative energy deficiency in sport factors

Physiotherapy action

• Stop high-impact loading.
• Do not attempt to “push through” focal bone pain.
• Refer for medical diagnosis and appropriate imaging.

2. Sacral insufficiency fracture

Typical presentation

• Older adult or person with low bone strength
• New deep low-back, buttock, sacral, groin, or posterior pelvic pain
• May follow a small fall, minor twist, transfer, or no clear event
• Progressive weight-bearing pain
• Functional decline: difficulty walking, standing, stairs, transfers

Risk factors

• Osteoporosis
• Older age
• Previous fragility fracture
• Long-term steroids
• Pelvic radiation
• Rheumatologic disease
• Low body weight or malnutrition

Physiotherapy action

3. Sacral traumatic fracture

Typical presentation

• Fall onto buttocks
• Motor vehicle collision
• Crush injury
• High-energy trauma
• Severe pain and difficulty weight-bearing
• Possible neurologic deficit, perineal symptoms, bladder/bowel change

Physiotherapy action

4. Sacral tumour, metastasis, or chordoma

Possible presentation

• Constant progressive sacral pain
• Pain at rest or pain that is not meaningfully altered by mechanical testing
• Night pain, especially with weight loss, fatigue, cancer history, or neurologic signs
• Bowel/bladder/sexual dysfunction or sacral sensory symptoms in advanced cases
• Palpable mass is uncommon but possible

Physiotherapy action

5. Infection

Possible presentation

• Severe focal pain
• Fever or systemic illness, though fever may be absent
• Recent infection, surgery, injection, wound, or immunosuppression
• Pain disproportionate to examination
• Rapid symptom progression
• New neurologic deficit in advanced disease

Physiotherapy action

6. Cauda equina or conus medullaris syndrome

Possible presentation

• Urinary retention, incomplete emptying, altered urinary sensation, overflow incontinence
• Saddle or perineal numbness
• New bowel dysfunction
• Bilateral sciatica or bilateral neurologic symptoms
• Progressive leg weakness
• Sexual dysfunction
• Reduced anal tone may be present, but do not delay referral to wait for this sign

Physiotherapy action

7. Inflammatory sacral pain

Possible presentation

• Insidious onset before approximately age 45
• Morning stiffness
• Improvement with movement or exercise
• Lack of improvement with rest
• Waking in second half of night, eased by getting up
• Alternating buttock pain
• Personal/family history of psoriasis, uveitis, inflammatory bowel disease, or spondyloarthritis

Physiotherapy action

9. Objective Examination: Safety and Priorities

Do not proceed with aggressive testing if:

• Emergency neurologic signs are present
• Fracture is suspected
• Infection is suspected
• Malignancy is strongly suspected
• The patient is systemically unwell
• Severe unremitting pain is disproportionate
• There is acute inability to weight-bear after trauma

If screening is negative and presentation appears mechanical

• Observation and gait
• Functional transfers
• Sit-to-stand
• Walking and stair tolerance
• Lumbar, hip, and pelvic movement
• Neurologic screen when indicated
• Local palpation only if safe
• Loading tolerance and symptom response
• Functional aggravating tasks

Important point

10. Physiotherapy Referral Decision Guide

11. Simplified Documentation Template

Subjective screening

Past medical history checklist

• Current or previous cancer
• Osteoporosis/osteopenia/previous fragility fracture
• Recent trauma or fall
• Long-term corticosteroid use
• Pelvic radiation
• Diabetes or immunosuppression
• Recent infection, surgery, injection, wound, or procedure
• Intravenous drug use
• Inflammatory arthritis/spondyloarthritis
• Neurologic disease or spinal surgery
• Anticoagulant use
• Pregnancy/postpartum/lactation
• Eating disorder, low energy availability, menstrual irregularity
• Bowel, urinary, reproductive, or pelvic disorder

Emergency neurologic screen

• Saddle/perineal numbness
• Bilateral leg symptoms
• New/progressive leg weakness
• New urinary retention or altered urinary sensation
• Overflow incontinence
• New fecal incontinence
• New sexual dysfunction with neurologic symptoms

Review of systems

• Constitutional: fever, chills, sweats, weight loss, fatigue, appetite change
• Neurologic: numbness, weakness, gait change, saddle symptoms, bladder/bowel/sexual change
• Musculoskeletal: trauma, fracture risk, inflammatory pattern
• Cardiovascular: syncope, vascular disease, abdominal/pelvic vascular symptoms
• Pulmonary: cough, dyspnea, cancer history
• GI: abdominal pain, bowel change, rectal bleeding, pain with defecation
• GU: dysuria, hematuria, frequency, urgency, retention
• Gynecologic/reproductive: pregnancy, abnormal bleeding, pelvic pain, cyclical symptoms
• Skin: wound, rash, pilonidal disease, redness, swelling, drainage

12. Key Examination Pearls

1. Pain location does not establish tissue source. “SI pain” can be sacral, lumbar, hip, pelvic, neurologic, or visceral in origin.
2. Never miss sacral neurologic symptoms. Ask directly about saddle sensation, urinary retention, altered urinary sensation, bowel control, and sexual function where relevant.
3. Think fracture without major trauma in patients with osteoporosis, steroid exposure, pelvic radiation, older age, low energy availability, or substantial training increase.
4. Use a cluster, not a single red flag. Isolated night pain or age alone is non-specific. The combination of history, risk factors, systemic symptoms, and examination findings directs referral.
5. Persistent, progressive, non-mechanical pain is not routine physiotherapy pain until a serious cause has been considered.
6. If unsure, refer. Screening aims to reduce delay in diagnosis, not to diagnose cancer, infection, fracture, or cauda equina syndrome independently.