Pelvis Lecture

Pelvic Girdle Pain

Presenter Information

  • Name: Elizabeth Montemagni, PT, MS, DPT

  • Course: PHTH 672 MSK II

Low Back Pain Classifications

  • LBP with Mobility Deficits

    • Treatment: Mobilization/Manipulation

  • LBP with Movement Coordination Impairment

    • Treatment: Stabilization

  • LBP with Lower Extremity Pain

    • Options:

    • Direction-Specific Exercise

    • Mechanical Traction

  • LBP with Spinal Stenosis

  • LBP with Altered Neurodynamics

  • Subgroup: Low Back-Related Leg Pain (LBRLP)

    • Related to: Facet joint, Trigger Points (TrP)

  • Predominant Pain Mechanisms

    • E.g., Central Sensitization

  • Chronic LBP/Lumbopelvic Pain Related to Motor Control

  • Pelvic Girdle Pain (PGP)

- Pregnancy-Related Pelvic Girdle Pain
Functional Pelvic Girdle Structure

  • Pelvis: The crossroads of human function involving force generation, load transfer, and stabilization

  • Key Components:

    • L4/L5 Motion Segment: Includes disc and facet joints

    • Sacroiliac Joints: Connect illia (plural of ilium) with the sacrum

    • Pubic Joint: Pubic symphysis (PS)

    • Hip Joints: Connections to the lower extremities

    • Soft Tissues Attachments

    • Lower Extremity Muscles (22 total):

      • Tensor Fasciae Latae (TFL)

      • Sartorius

      • Rectus Femoris (RF)

      • Gluteus Maximus, Medius, and Minimus (3 types)

      • Iliopsoas

      • Gemelli (2)

      • Obturators (2)

      • Piriformis

      • Hamstrings (3 types)

      • Adductors (3 types)

      • Gracilis

      • Pectineus

      • Quadratus Femoris (QF)

    • Trunk Muscles:

      • Abdominals (4 types)

      • Pectoralis Major

      • Latissimus Dorsi

      • Erector Spinae (3 types)

      • Quadratus Lumborum (QLs)

      • Multifidi

- Fascia and Ligaments
Ligaments of the Pelvic Girdle

  • Anterior Longitudinal Ligament

  • Iliolumbar Ligaments

  • Intertransverse Ligament (L5)

  • Supraspinous Ligament

  • Anterior Sacroiliac Ligament

  • Sacrotuberous Ligament

  • Symphysis Pubis Joint

  • Inguinal Ligament

  • Sacrospinous Ligament

  • Facet Joint Capsule

- Posterior Sacroiliac Ligaments
Pelvic Girdle Pain (PGP) Overview

  • Isolation: Functionally cannot be separated from thoracolumbar (T-L) spine and lower extremities (LEs)

  • Link to Stability Issues: PGP is often linked to problems in lumbar spine (L/S) and hip stability

  • Exclusion of Disorders: Must exclude gynecological or urological disorders (Pelvic Floor Dysfunction)

  • Characteristics:

    • Multifactorial causes including pregnancy, trauma, arthritis, gait abnormalities, posture, strength, muscle length, foot function, and asymmetrical loading

    • Recognized as a specific form of low back pain that is diagnosed after eliminating L/S and hip issues

  • Measurement Difficulties: Measuring/quantifying actual sacroiliac joint (SIJ) and pelvic motion is challenging

  • Focus on Movement Patterns: Rather than isolated measurements, observe movement patterns

  • Cluster Symptoms & Tests: This leads to a multifactorial diagnosis which informs an impairment-based treatment approach

PGP Classifications

  • Joint Dysfunction

    • Types:

    • Hypermobile

    • Hypomobile

  • Motor Control Dysfunction

  • Endurance Issues

- Activation Problems
Sacroiliac Joints and Pubic Joint

  • Joint Type: Planar joints designed for load transfer and mobile stability

  • Motion Characteristics:

    • Limited motion, but capable of shearing

    • A dense ligamentous system is present to counteract shearing forces

  • Movement Quality: Emphasis on quality of movement over quantity

  • Pain Patterns: SIJ pain generally radiates into the L5 and S1 dermatome and myotome pattern, usually not extending distal to the knee unless complicated by referred conditions

  • Load Transfer Issues:

    • Abnormal loading can lead to pain in the local and neighboring joints

    • Joint asymmetry and muscle/fascia dysfunction may contribute

Iliac and Sacral Motions
Ilium (Innominate)

  • Types of Motions:

    • Anterior Rotation

    • Posterior Rotation

    • Inflare/Internally Rotated (IR)

    • Outflare/Externally Rotated (ER)

    • Upslip

    • Downslip

  • Assessment: Assessments performed via palpation of Anterior Superior Iliac Spines (ASIS) and Posterior Superior Iliac Spines (PSIS)

Sacrum Motions

  • Motions Defined by Sacral Base Movement:

    • Flexion: Nutation

    • Extension: Counternutation

    • Rotation: Torsion

- General Rule: Sacral motion is typically opposite that of spinal motion, but it follows the lumbar/sacral (L/S) at end ranges of flexion/extension
SIJ Pathology

  • Diagnosis:

    • Requires clustering history and symptoms

  • Provocation Testing (Special Tests):

    • Location of Pain: Distinguish between precise or referred (Fortin Finger Test - targeting area 1cm from PSIS)

    • Palpation: Moderate depth palpation is appropriate

    • Strength Testing: Hip Abduction Manual Muscle Testing (MMT)

    • Motion Palpation Testing: Assess for symmetry and mobility

    • Quadrant Length Screening: Use of radiographs to distinguish between leg length discrepancies (LLD) versus scoliosis

  • Activity Pain Responses:

    • Prolonged sitting, standing, or crossing legs often exacerbates symptoms

    • Patients often change positions frequently due to discomfort

    • They have a low tolerance for single-leg stance and asymmetrical loading

  • Clinical Prediction Rules:

    • Criteria for SIJ involvement includes having +3 out of 5 on notable tests:

    • Compression

    • Distraction

    • Thigh Thrust

    • Sacral Thrust

    • Gaenslen

    • Alternative tests: Compression, Distraction, FABER, Thigh Thrust, Gaenslen

Differential Diagnosis

  • Conditions to Rule Out:

    • Trochanteric Bursitis (assessed via palpation)

    • Hip Labral Issues (specific special tests)

    • Piriformis Syndrome (similar assessments)

    • Myofascial Trigger Points (muscle length and trigger point pressure)

    • Lumbar Spine Disc Herniation (notable peripheralization or centralization responses)

    • Lumbar Spine Facet Mobility Dysfunction (pain localized to the affected facet)

    • Femoral Stress Fractures (assessed with Fulcrum Test - image available)

    • Pelvic Floor Dysfunction (patient may report bowel, bladder, or sexual dysfunction)

    • SIJ Pathology: Patients rarely report pain superior to L5

- SIJ pain typically felt between the posterior iliac crest and gluteal fold, and within 1cm of PSIS
Pelvic Girdle Pain Treatment
Key Approaches

  • Education: Essential!

  • Recognize PGP as a potential category within chronic LBP that may include peripheral or central sensitization

  • Biopsychosocial Approach:

    • Lessening the emphasis on finding a pathological source of pain

    • Focus on altering beliefs and behaviors about pain

    • Education assists patients in understanding their pain and that activity (exercising/moving) does not damage tissues

  • PGP Consideration:

    • Less a diagnosis and more a symptom; treatment should focus on modifying the movement patterns caused by PGP

    • Emphasize proper posture for joint protection

Treatment Strategies

  • Movement Coordination Disorders:

    • Often characterized by hypermobility, reduced strength, and endurance or coordination impairments

    • Treatment includes Neuromuscular Re-education (NMR) focusing on stability, strength, and endurance for the trunk and pelvis

    • Important Note: LBP often inhibits gluteal function and hip extension, leading to a hamstring-dominant movement pattern – this needs correction!

  • Joint Hypomobility:

    • Treatment includes mobilization/manipulation and NMR for stability, motor control, and endurance

  • Joint Hypermobility:

    • NMR for stability, motor control, and endurance, potentially assisted by pelvic belts

  • General Note:

    • Emphasis on endurance and motor control rather than strength for achieving stability

    • Treatment may involve Trigger Point Release, Soft Tissue Mobilization (STM), or Myofascial Release (MFR) when needed

- Ensuring muscle strength symmetry is vital for effective load transfer
Pelvic Girdle Pain Treatment – Self Mobilization

  • Hip Abduction:

    • Goal: Compress the SIJ

  • Hip Adduction:

    • Goal: Distract the SIJ

  • Muscle Energy Technique for Innominate Rotation:

    • Utilizes hip flexors or extensors to realign the innominate

    • Example: For a right anteriorly rotated innominate, contract the right hip extensors and left hip flexors to correct alignment.