MS SI/Pelvic Exam, tx

degenerative changes population

-are increasingly common with advancing age and may occur secondary to disorders in which movement is decreased - Degenerative changes are also associated with chronic structural abnormalities such as leg length discrepancies, scoliosis, or pelvic asymmetries, or hip disease • In patients with unilateral hip disease degenerative changes are usually found in the contralateral sacroiliac joint

hypermobility lesions

-are rare and occur in one of two situations - According to Maitland, the first situation is secondary to instability of the symphysis pubis • This occurs predominantly in athletes • The second situation occurs in young females, usually during or soon after pregnancy - Ligaments may remain lax for up to 6 to 12 months after delivery (or 3-4) - Occasionally the symphysis may become a truly mobile joint, with pelvic instability as a result

how is SI pain described?

-as a dull ache and is characteristically experienced over the back of the sacroiliac joint and buttock • The pain can refer to the groin, over the greater trochanter, down the back of the thigh to the knee, or down the lateral or posterior calf to the ankle, foot, or toes • Pain may also be referred to the lower abdomen—pain is then felt in the iliac fossa and is usually associated with a localized area of deep tenderness over the iliacus muscle known as Baer's sacroiliac point • Because the pelvis is a bony ring, pain may also be experienced anteriorly over he pubic symphysis or the adductor tendon origin

neurological deficits

-can be present if the sacroiliac joint is affected (or ALS) - Is there a hard neurological sign? (hoffman)

asymmetry of the ASIS

-could be a pseudo-disease finding ( most people have it, but no sx, pain) - It has been suggested that people without pain as asymmetric as those with pain

LLD

-hypomobility also occur insidiously and may be associated with certain structural faults such as asymmetrical development of the pelvis or unequal leg length • LLD (functional or structural), and pelvic muscle length asymmetry are considered prime factors in detecting sacroiliac dysfunction - According to Bourdillon, in patients with leg length inequality there is a natural tendency for the pelvis to adopt the twisted position which most nearly levels the anterior— superior surface of the sacrum -pregnancy

what segment of the spine is responsible for a large percent of LBP

L5-S1

how to rule out other sinister phenomena

Myelopathy, fractures - Unexplained pain • Swelling isolated in the sacral base • Pain with rectal examination • Pain with all hip ROM (Sign of the Buttock Test) - Non-Mechanical Disorders - Ankylosing spondylitis, psoriatic arthritis, Reiter's syndrome, SLE, gout, Padget's disease, tuberculosis, Sjoegren's syndrome

forward flexion

PSIS should move up -if hypomobile, would not see that movement (one would move up, one would stay static)

SI dysfunction pain

associated with pain that arises from the sacroiliac joint and is caused by a lack of symmetry, or alteration in the stability of the sacroiliac joint -pain: reaching for the wallet in the back pocket

nutation

base of the sacrum moves anterior to the inominates with a backbend- (not APT) pelvis moves posterior, sacrum moves anterior, spine increases in extension/lordosing (sacrum increases in flexion/kyphosis)

counternutation

base of the sacrum moves posterior to the inominates

what is the most useful palpation of the pelvis

deep palpation of the pubic symphysis - Pain with palpation can be associated with osteitis pubis or instability of the pubic symphysis - Have the patient find their pubic symphysis and place their thumb over it—palpate over the patient's thumb

how to palpate the L5-S1 facet

find halfway between the PSIS and L4

pain patterns in the thigh

if its just in the thigh - chances are its a thigh problem -if not radiating

clinical signs of SI dysfunction

pain and local tenderness, with increased pain on position changes such as ascending and descending stairs, or rising from sitting or lying to standing

how to rule out fractures

pubic percussion test -if you think there was a trauma involved and you want to identify a fracture -have pt place stethescope head on the pubic symphysis -use tuning fork, place on kneecap on side of pain: will vibrate up to the pelvis... if there is no fracture, will hear a nice smooth sound -if it sounds like crackers, crumbling papers = fracture

SI dysfunction can also lead to...

urinary problems

what can palpable pudginess indicate

weakness, atrophy, lumbosacral plexus issue

degenerative changes- cartilage

• Degenerative changes first involve the iliac surface where the cartilage is thinner than on the sacral surface -The cartilage changes are similar to those of peripheral joints • Vleeming and associates consider the non-inflammatory fibrous and radiological visible hyaline cartilage covered ridges to be physiological - A response to joint stress and an adaptation to greater stability

extension

• During extension the opposite movements should occur -look for even movements -PSIS should move down?

hip flexion (PSIS movement)

• Hip movements performed are also affected by sacroiliac lesions • As the patient flexes each hip maximally, the examiner should observe the range of motion present, the pain produced, and the movement of the PSIS (GilletTest) -should have movement that causes PSIS to move down, if not (moves up or stays the same), hypomobile • Normally, flexion of the hip with the knee flexed to 90 degrees or more causes the sacroiliac joint on that side to drop or move caudally in relation to the other sacroiliac joint • If this drop does not occur it may indicate hypomobility on the flexed side • If the joint is hypomobile, the thumb will move up with hip flexion

what tests should you do if pt cannot be prone

• If a patient cannot assume prone posture, the clinician may choose to use the: Thigh Thrust Sacral Compression Test Sacral Distraction Test Patrick Test Gaenslens Test

why does the SIJ satisfy criteria to qualify as a pain generator

• It has a nerve supply • It is susceptible to disease or injuries that are known to be painful (infection, trauma, malignancy, etc.) • It is capable of causing pain that is clinically detectable

what should you look at from a posterior standing view

• Level of the iliac crests • Level of the posterior superior iliac spines • Level of the ischial tuberosities • Level of the gluteal folds

mechanoreceptors in the SI joint

• Most of the mechanoreceptors in the sacroiliac joint have a nociceptive function which suggests that the sacroiliac joint may be a source of lower back pain and it has little proprioceptive function *mechanical, focus on L5-S1 (differentiate) asymmetrical irritation/rubbing can present as LBP

inflammatory disease and infections

• Other conditions to be considered in the differential diagnosis include infections and metabolic conditions - Inflammatory sacroilitis conditions are either infectious or seronegative spondyloarthropathies • The major spondyloarthropathies (arthritis) are ankylosing spondylitis, Reiter's syndrome, and psoriasis - Infections usually involve only one sacroiliac joint and may be a staphylococcal or tubercular infection, or an infection due to intravenous drug abuse

provocation based testing

• Restrictive use of isolated pain provocation tests has questionable utility • In construct, some have promoted the use of pain provocation tests only when clustered together with other tests • When compared to palpation and movement based assessment, pain provocation tests yield higher reliability and diagnostic value scores for diagnosing sacroiliac joint pain (when clustered) • There is a cluster of pain provocation tests that are used to implicate the sacroiliac joint as the origin of pain—the tests are not designed to identify a dysfunction nor do the tests solely implicate the sacroiliac and rule out the lumbar spine • Several studies have purported the benefit of combining selected sacroiliac joint tests to improve the reliability and diagnostic value - According to Laslett et al. for the four tests sensitivity is 88 and specificity is 78 for diagnostic value of the selected tests - According to Van der Wurff et al. for the four tests sensitivity is 85 and specificity is 79 for diagnostic value of the selected tests

resisted testing

• Rost et al. suggested that resisted sidelying abduction is symptomatic with patients experiencing hypermobility of the sacroiliac joint and pubic symphysis

SI pain

• Sacroiliac joint pain has no special distribution of features and is similar to symptoms arising from the lumbosacral structures -There are no provoking or relieving movements or positions that are unique or especially common to the sacroiliac joint

hip flexion (ischial tube movement)

• The examiner then moves one thumb to the ischial tuberosity and the patient again flexes the hip as far as possible • Normally the thumb over the ischial tuberosity moves up and lateral

ASIS movement

• The examiner then sits in front of the standing patient and palpates the ASIS • Testing one leg at a time, the [patient pivots the leg on the heel into medial and lateral rotation • When doing these movements, the ASIS should move medially and laterally

active movements

• The movements of the spine put a stress on the sacroiliac joints as well as on the lumbar and lumbosacral joints • Rule out the lumbar spine • Rule out the hip

subluxing the SI joint

• The sacroiliac joint can sublux • Secondary to the auricular surfaces, Vleeming et al. (1990) have proposed that it is theoretically possible for the joint to move and assume a new position -This new position is locked into a position of displacement -The amount of displacement may be so minute that radiographic verification is unlikely holding stomach in- take away affect of back muscles- not natural- causing muscle imbalance (janda)

passive accessory movements of the SI joint

• There are no studies that have assessed the merit of passive accessory movements of the sacroiliac joint • Traditionally, many clinicians have suggested that conventional P—A and A—P may be beneficial in identifying movement related pain and could be helpful in identifying movement related pain

thigh thrust

• Thigh Thrust (Ostgaard Test)—involves a downward thrust of the thigh that causes a posterior translation of the innominate on the sacrum - Patient is positioned in supine and the clinician stands on the opposite side of the painful side of the patient -The painful sided knee is flexed to 90 degrees - The clinician places his or her hand under the sacrum to form a stable bridge for the sacrum - A downward pressure is applied through the femur to force a posterior translation of the innominate on the sacrum - The force is held for 30 seconds and if no pain occurs a slight bounce is given to try and further provoke the joint is used bend leg up, bring it over towards you, put hand between legs over pelvis (stabilizes sacrum, glide inominant on the joint) -PT stride steps,puts weight through hand on the knee -can manipulate in this position

hypermobility population

• This occurs predominantly in athletes • The second situation occurs in young females, usually during or soon after pregnancy - Ligaments may remain lax for up to 6 to 12 months after delivery (or 3-4 months) - Occasionally the symphysis may become a truly mobile joint, with pelvic instability as a result

how to rule out myelopathy

• Upper motor neuron lesion possibly related to a central cord compression - Test for clonus (3 beats or more) -Babinski (positive) - Gait and balance dysfunction - Supra-patellar and brachioradialisreflex (hyperreflexive) - Hoffmann's Test (best test for sinister origin)

compensatory LLD and torsion

• When an inominate torsion is present the appearance of an unequal leg length is presented - Compensatory anterior rotation of an inominate is associated with a short lower limb - Compensatory posterior rotation of an inominate is associated with a long lower limb *if you have a shorter limb, you compensate by anteriorly rotating the pelvis on that side to make it "longer"

prone active movment

• With the patient lying prone, the examiner palpates the PSIS and asks the patient to actively extend the hip • On extension, the examiner expects the PSIS and sacral crest to move superiorly and laterally • If the PSIS does not move superior and lateral, it indicates hypomobility with the possibility of a posteriorly rotated ilium

hypomobility lesions usually occur in...

• young people and may be associated with movements that place a rotational stress on the sacroiliac joint -Movements of golfing or ballet dancing would be prime examples -Hypomobility may also develop after pregnancy or trauma

what to observe in supine

Are the ASIS's level and equidistant from the midline of the body Are the legs the same length Is there the same degree of toe out on each side Are the hamstrings tight Are the hip external rotators tight

what to observe in prone

Are the PSIS's level and equidistant from the midline of the body Is there any unilateral or bilateral spasm of the erector spinae muscles Are the buttock contours or gluteal folds normal • The painful side is often flatter if there is loss of tone in the gluteus maximus muscle Are the ischial tuberosities level Assess palpable pudginess

capsular pattern of the SI joint

Pain when the joints are stressed

four provocation tests advocated by cook

Thigh Thrust Compression Test Distraction Test Sacral Thrust clustering special tests in the SI/pelvis is very sensitive

baer's SI point

This point is located about two inches from the umbilicus on a straight line from the ASIS

what is nutation resisted by

"PISS" - Interosseous ligament - Sacrotuberous ligament - Posterior iliolumbar ligament - Sacrospinous ligament

sacral thrust

(Sacral Spring Test)—the sacral spring test theoretically provides an anterior shearing force of the sacrum on both of the ilia - The patient assumes a prone position - The clinician palpates the second or third spinous process of the sacrum then applies a series of five to seven downward thrusts on the sacrum at S3 if quick thrust or mobs causes pain = positive

passive physiological anterior rotation

(counternutation) - The patient assumes a sidelying position, the painful side up - The painful sided leg is extended and the plinth side leg is flexed to 90 degrees— the motion is the mirror image of passive physiological nutation in which the lower leg is wrapped around the waist of the clinician - The clinician cradles the top leg with the caudal side hand and encourages further movement into hip extension - The cranial side forearm is placed on the PSIS and promotes anterior rotation of the innominate take the lower extremity and hook on the PT's hip, arm underneath upper leg, shoulder against thigh, interlace fingers behind leg and rotate trunk into hip ext

passive physiological posterior rotation

(nutation) -Patient assumes a sidelying position with the painful side placed upward - The painful sided leg is flexed to 90 degrees to engage the pelvis and promote passive physiological flexion - The clinician then situates his or her body into the popliteal fold of the painful sided leg to "snug up" the position bring upper leg forward, hook it on PT's hip - one thenar eminence on ASIS, other goes on ischial tuberosity (posterior rotation of inominant) -is it tight or does movement hurt? -flex hip by rocking body -assessment and tx tool (if you suspect a hypomobile inominant -helps move into posterior rotation (1-1 1/2 mins)

how to rule out the hip

- Hip Scouring or Hip Quadrant • Used to identify hip labrum tears - Faber Test • Demonstrates good diagnostic value to differentiate hip osteoarthritis

age and SI dysfunction

- Hypomobility is likely to be seen in men between 40 and 50 and in women after the age of 50 - Apophyseal injuries and avulsion fractures occur in young athletes (trauma)

counternutation is resisted by

- Long dorsal ligament - Anterior iliolumbar ligament

U and B A-P movements of the innominate (supine)

- Patient is supine and resting symptoms are assessed - For a unilateral A—P, the clinician applies a light posterior pressure at the ASIS to promote posterior rotation of the innominate • For a bilateral A—P, the same process occurs with the contact points of both ASIS • The clinician applies 5— 30 seconds of repeated end range oscillations to determine the behavior of the patient's comparable sign c-grip on ASIS, see straight down force - stop at first sight of pain

how to rule out L-spine

- Repeated lumbar extensions (if the patient centralizes, they are not a pelvic girdle patient) - Repeated lumbar flexion - Repeated lumbar side flexion - Lumbar rotation with overpressure - Passive accessory testing of the lumbar spine

location of pain in the pelvis

- Sacroiliac pain is usually a deep, dull, undefined pain that tends to be unilateral - It can be referred to the posterior thigh, iliac fossa, and buttock on the affected side - If the pubic symphysis is involved it would generally result in groin pain and/or inflammatory involvement with adjacent structures - Pubic symphysis dysfunction is usually resultant from direct trauma

hypermobility tx

- Simple mobilizing techniques localized to the sacroiliac joint structures are very effective after careful exclusion of problems from the intervertebral joints • Use of sacroiliac belts appears to be justified in theory, but the outcome data is not available

how to rule out radiculopathy

- Straight Leg Raise and Slump Sit Testing - Lower Quarter Screen (• Reflexes • Sensation • Manual Muscle Testing) - Functional Strength Testing (• Unilateral sit to stand • Functional squat • Heel walking/toe walking)

U and B A-P movements of the innominate (prone)

- The patient assumes a prone position and resting symptoms are assessed -For a unilateral P—A the clinician applies a light anterior pressure at the PSIS with a thumb pad contact to promote anterior rotation of the innominate • For a bilateral P—A, the same process occurs with the contact points of both PSIS using the pisiforms of both hands on PSIS, straight down -repeated P-A on sacrum

SI compression test

- The patient assumes a sidelying position with his or her painful side up - After assessment of resting symptoms, the clinician then cups the iliac crest of the painful side and applies a downward force through the ilium for up to 30 seconds • As with other sacro-iliac tests, considerable vigor is required to reproduce the symptoms S/L, hand over ilium (not greater troch) -hand over hand, downward mob -compresses SI joint and oscillate to find end of range -hold at end range for 30 seconds

standing bend over test

- The patient is asked to bend forward and the symmetry of movement of the PSIS is noted - In the first 45 degrees the sacrum will move forward (nutate) -Near 60 degrees, the sacrum will begin to counternutate or move backwards • During sacral counternutation the two PSIS will move upward equally

SI distraction test

- The patient is in a supine position - The medial aspect of both ASIS is palpated by the clinician - The clinician crosses his arms creating an X at the forearms and a force applied in a lateral-posterior direction - The clinician applies a vigorous static force for 30 seconds in attempt to reproduce the comparable sign thenar eminence on ASISes, push away from each other, hold up to 30 seconds

gaenslens test in supine

- The patient is positioned so that the test hip extends beyond the edge of the table - The patient draws both legs up onto the chest and then slowly lowers the test leg into extension -- add overpressure - Pain in the sacroiliac joints is indicative of a positive test

step and bend for posterior rotation

- The patient places the painful side extremity up on a 2 to 3 foot platform - The patient then leans forward placing a backward or posterior torque on the innominate - The patient repeats the posterior rotation technique to determine if pain is reduced with repeated movements facilitates posterior rotation of the innominant -put affected leg up on the step, arms over test, bend forward, repeat 5-10x -see if sx are provoked -can repeat after a tx to see if things have improved

lunge for anterior rotation

- To test this motion, the patient assumes a lunge position, the painful extremity functioning as the trail leg - The patient lunges forward until force is encountered on the posterior trail leg - The patient repeats the anterior lunge maneuver to determine if pain is reduced with repeated movements lunge on unaffected side, leaving the trail leg to be the affected side: forces movement on a stable pelvis -must be able to take up compensatory movement -repeated movements up to 10 times

prevelance of SI joint pain

-According to epidemiological research, the true prevalence of sacro-iliac joint pain is approximately 13% -The female population is associated with a higher incidence of sacro-iliac joint pain and pelvic girdle pain

when the pain occurs for SIJ dysfunction

-Pain that is caused by sacroiliac joint problems is usually felt when turning in bed, getting out of bed, or stepping up with the affected leg (usually transfers or unilateral activities) • Often, the pain is constant and unrelated to position - Climbing or descending stairs, walking, and standing from a sitting position all stress the sacroiliac joint

traumatic incidents

-Was there any known mechanism of injury • Inadvertent step off a curb.. thinking there is one more step, or forgetting there is one more step • Overzealous kick • Fall on the buttocks (usually one buttock... B buttocks = lumbar issue, coccyx fracture) • Any other recent falls, strains, or twists -middle aged women riding a bike

osteitis condensans IIii

-a non-inflammatory condition is characterized by a condensation of bone on the iliac side of the sacroiliac joint - Its nature is uncertain but it probably represents a bony reaction to unequal stress in this joint - It is usually bilateral and occurs mostly in young adults, more commonly in postpartum women • It typically disappears with menopause, and it is important medically as it mimics inflammatory disease like the bone is sweating with microcrystals... happens in the joint -reaction to unequal stress -asymmetric or degenerative process -not common