Pelvic Girdle Pathology and Exam

Diagnostic

No Single test can be used

pain at inferior sulcus of SIJ and (+) pain provocation stress test

• direct tenderness

• zone of hyperirrability and tissue texture changes

• eval of referral zones

• fascial or musculotendinous restrictions

• abnormal regional length-strength muscle relationship (Lumbar and spine)

• Postural analysis

• True leg length and functional leg length determination

• static and dynamic osseous landmark exam

• provocative testing (traditional test, motion demand test, ligament tension tests)

Lumbopelvic ROM: Forward Bending

Normal finding: posterior displacement of pelvic girdle, sacral nutation bilaterally and symmetrically relative to innominate and remains nutated throughout

repeat several times to note consistency

(+) inadequate load transfer= lack of anterior pelvic tilt, excessive flexion of thoracolumbar spine, twisting of pelvic girdle

Lumbopelvic ROM: Backward Bending

Normal finding- anterior displacement of pelvic girdle, sacral counternutation, bilaterally and symmetrically relative to innominates and remains. Lumbar segments extend without hinging or shifting

(+) lack of posterior pelvic tilt, excessive thoracolumber extension, twisting of pelvic girdles

Lumbopelvic ROM: side bending

Normal finding: contra lateral pelvic displacement, contra lateral innominate rotates posterior relative to ipsilaterally. Sacrum rotates contralaterally while the lumbar spine side bends

Anterior Innominate Rotation

PSIS rotates supeiorly while ASIS goes inferiorly

Posterior innominate Rotation

ASIS rotates superiorly while the PSIS moves inferiory

Shear Superior Innominate Shear

Both the ASIS and PSIS move superiorly together

Down Slip of Innominate

Both ASIS and PSIS move inferior together

Inflare

Movement in the transverse plane

Internal / medial Rotation

Functional tests: dynamic test

Functional squats: ankles dorsiflex, feet prone, pelvic girdle anterior tilt

Alternating unilateral standing: stand then shift to univolved leg. Maintain for up to 30 sec or until pain is recreated. Than shift onto the involved leg, maintained for up to 30 sec or pain is reproduced

(+) inability to maintain unilaterally stance for 30 seconds and inability to shift weight without pain

Functional test: static

Palpating for landmarks, however it is better to palpate for these landmarks during dynamic movements

Inner unit of muscles that contribute to SIJ instability

• diaphragm

• Pelvic floor muscles (floor)

• Multifidus (posterior) disc hernation

• Transverse abdomimis (anterior) herniation

Outer muscle unti that’s contribute to SIJ instability

• posterior oblique System

• Anterior oblique system

• Lateral system

• Deep longitudinal system

Posterior oblique system

Force closure of SIJ

Give the necessary force for SIJ so work of

• latissimus Doris

• Glutes max

• Thoracolumbar fascia

Anterior oblique system

Tested through the active straight leg raise

Force closures of pubic symphysis (because on the anterior side of the body)

External / internal oblique, contralateral adductors

Lateral system

Gluteus med/ min, contralateral adductors

Deep longitudinal erector spinae

Force closure of SIJ and compression of L5-S1

For stability along the SIJ

Deep lamina of throacolumbar fascia

Scaroturberous lig

Bicep femoris

If SIJ joint is hypomobile

Use joint mobilizing tech, muscle release tech, and exercises that are designed to restore normal optimal alignment and controlled mobility

If joint is hyper mobile or unstable

Uses tech and exercises that are designed to stabilize or balance forces around the hyper mobile or unstable joint., these include exercises to control joint motion and on occasion, joint compression through the use of an external brace (SIJ Belt)

Joint showing signs of excessive compression (due to intrinsic factors or extrinsic)

Uses tech based on the cause of compression

• fibrosis benefits from the use of specific passive articulate mob tech

• Joint compression cured by overactivation of muscles benefit from muscle energy tech trigger point and biofeedback

Muscle Energy Tech (MET)

Essentially creates a reversal of action of the muscle

Uses the principle of reciprocal inhibition on antagonistic muscle

Uses resisted active contraction of the hip flexors to create anterior rotational force on the innominate

Uses resisted active contraction of the hip extensors to create posterior rotational forces on the innominate

Contraindications foe grade 3-5 mob

• cancer

• Neurological conditions

• Joint instability

• Joint fusion

• Open wound

• Vascular issues

• Inflammation conditions

• Connective tissue disease

• Hyper mobility syndrome

• Bone disease

• Tuberculosis

Spondylarthropathies

Inflammatory arthritic conditions

• inflammatory arthritis presenting with pain and stiffness

• Seronegative Spondylarthropathies: absence of rheumatoid factor

• Typically asymmetric and involve LE

• Inflammation at the tendon insertion, can also include skin, mucus membrane impairments, bowel complaints, eye involvement, aortic root dilation

Anklylosing Spondylitis

Chronic rheumatoid disorder that is usually progressive

Men most common in the spine

Women most common in peripheral joints

Osteitis Pubis (Athletic Pubalgia)

An association between ROM limiting Hip disorders (femoral acetabular impingements)

It is seen in individual who participate in activities that create continual shearing forces at the pubic symphysis

Usually appears during the 3rd or 4th decades of life, and more common in men

The public tubercle and pubic symphysis are painful in up to 22% of patients

4 stages of Osteitis Pubis

1. Pain located in the unilateral kicking leg and pain level that worsens after training

2. Bilateral inguinal pain and pain levels that worsen with training

3. Bilaterally inguinal and lower abdominals muscles pain, pain level that worsens with kicking, spiriting, changing direction, long walks and sit to stand transitions

4. Bilateral inguinal, lower abdominal and LBP or pain level that worsens with defecation, sneezing, walking, and prevent ADL performances

Symphysis Pubic Dysfunction (SPD)

Diastasic symphysis pubis (DSP)

Usually occurs during pregnancy because of the ligament laxity associated with it

The pelvic misalignment results in increased pressure on the pubic symphysis cartilage, with subsequent pain

Subjectively the pt will report:

• pain with any activity that involves lifting one leg at a time or parting the legs

• Usually demonstrate an antaglic gate waddling gait

• Tenderness over the anterior pubic symphyseal area

• Occasionally clicking can be felt or heard

Positive SIJ stress test (compression, distraction and FABER test)

Symphysis Pubic Disfunction types

Type 1: minor anterior damage, mild pubic symphysis

Type 2: wide diastasis

Type 3: Total diastasis

Symphysis Pubic Dysfunction management

• bed rest

• Pelvic supportive devices

• Walking with a device

• Patient education

• Swimming

Usually s/s resolved in 6-8 weeks with no lasting sequele

Coccydynia