Idiopathic Pelvic Girdle Pain (PGP) in relation to the Sacroiliac joint (SIJ) has generated much interest due to the complex articulations of the SIJ and the broad spectrum of clinical presentations. Pelvic girdle pain is an umbrella term that can have many causes. Sacroiliac joint pain either unilateral or bilateral, low back pain, gluteal pain and radiating pain in the leg are common complaints which can have many causes. Lumbosacral radicular syndrome (LSR) or sciatica can be one of them 13.
The purpose of this case study is to present a young patient’s chronic lumbo-pelvic complaints and symptoms, document the Physical Therapist’s Initial Evaluation findings, choice of special tests , interventions and clinical reasoning to help the patient improve her outcomes. This patient had a prior history of lumbar radiculopathy , new onset of right sided low back pain , right SIJ involvement , and pain across the pelvic girdle. Initial functional limitations were noted on the Modified Oswestry Low Back Pain Disability Questionnaire (62% Disability) and the Lower Extremity Functional Scale (40/80).
Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200
Over the course of rehabilitation, the patient improved scores on both the Modified Oswestry Low Back Pain Disability Questionnaire (15% Disability) and the Lower Extremity Functional Scale (65/80). While this case study demonstrates the relationship between structural misalignment of the lumbo-pelvic complex and improvement in a patient’s outcomes with physical therapy interventions, it has limitations including the inability to establish a cause-and-effect relationship. The study is also limited due to lack of long term follow up. The improvements in outcomes in this case suggest that clinicians may benefit from looking closely at structural misalignment as a possible source of pain and dysfunction and using this information to guide an effective treatment approach for lumbo-pelvic pain.
In today’s society , 70%-85% of individuals suffer from pelvic girdle pain (PGP) in their lifetime. Interest has arisen on the subject of the sacroiliac joint (SIJ) because of its direct involvement in PGP and lumbopelvic pain, but this is still underappreciated as a source of mechanical lower back pain10.
Research efforts have intensified on SIJ anatomy and biomechanics because of its predisposing position to pain and dysfunction in individuals suffering from lower back discomfort 10. There are many studies in the literature that explore the anatomy and biomechanics of the Sacroiliac joint as a contributor to lumbo-pelvic pain 2-9,14-15.
The following table demonstrates some of the complex anatomical and structural relationships of the SIJ.
Major muscles that may influence the SIJ
Erector Spinae, Mutifidus, Quadratus Lumborum, Gluteus maximus and Gluteus Medius , Piriformis Coccygeus, Semimembranosus and the Semitendinosus muscles
Attachments of lumbar musculature to SIJ
The Erector Spinae muscles Iliocoastalis and Longissimus both arise from the sacrum. The lumbar multidifus arises from the back of the sacrum, as low as the fourth sacral foramen, from the aponeurosis of origin of the sacrospinalis, from the medial surface of the posterior superior iliac spine, and from the posterior sacroiliac ligaments.
Attachments of pelvic musculature to SIJ
Glute maximus has attachments to the sacrum and coccyx; Piriformis has direct attachments to the SIJ as it crosses over and pulls the sacrum in an oblique direction . The Piriformis also has attachments to the Sacrotuberous ligament (STL)
Attachments of thigh musculature to SIJ
The long head of Biceps Femoris muscle has attachments to the Sacrotuberous ligament (STL). Current evidence describes the STL having attachments with the piriformis muscle, Obdurator internus, Semimembranosus and Semitendinosus muscles.
Given the complex intricate attachments of all the muscles listed above, lumbar and sacral positional dysfunction can contribute to the altered length tension relationship of the muscles of the pelvic girdle causing them to be in a hypertonic state resulting in persistent pain . Correcting lumbar, pelvic and sacral mis-alignment can reduce the biomechanical stress on the pelvic girdle thereby alleviating pelvic girdle pain.
This case study presents the cluster of a patient’s chronic lumbo-sacral complaints and symptoms, the physical therapist’s assessment, interventions and outcomes. This report demonstrates the relationship between structural misalignment of the lumbo-pelvic complex and rapid improvement in a patient’s symptoms and function when proper alignment and optimal length-tension relation of the pelvic girdle muscles is restored.
A young female presents to the clinic with complaints of near constant right-sided low back pain , right SIJ pain and pain across the right gluteals . She complains of intermittent pain extending into the right posterior thigh down the right leg to the plantar surface of the foot . She also reports history of plantar fasciitis in the right foot stemming from first pregnancy 8 years ago . She has had intermittent flare ups several times over the years , current flare up reported a month ago and symptoms are progressively getting worse. Patient reports prior history of right lumbar radiculopathy 5 years ago with residual numbness in two of her toes on the right foot. Patient states “The pain is very different this time. I noticed that it started when I did heavy yard work 4 weeks ago. It is worse when I try to get in and out of the car and I can’t really find a comfortable position to sit or sleep at night .” Patient works at a convenience store and stands for long periods of time. She finds herself “limping” by the end of a workday.
Patient had physical therapy 5 years ago which helped and is motivated to try therapy again to get better. She states that she had an MRI 5 years ago which showed “pinched nerves” in her lumbar spine , however she doesn’t have the report nor remembers what levels of the spine were involved.
Patient went to see her Primary Care Physician ( PCP) and was given prescription NSAIDS. She states that “the medicine has taken the edge off the pain and helps me get through the first half of the day, but there is no lasting relief”.
Modified Oswestry Low Back Pain Disability Questionnaire: 62% Disability.
The Lower Extremity Functional Scale (LEFS): 40/80
Special Tests: * Laslett’s 3/5 positive pain provocation tests for SIJ 7
RIGHT | LEFT | |
---|---|---|
Active SLR | Positive | Negative |
Repeated lumbar flexion in standing | Does not make low back and gluteal pain worse | |
Repeated lumbar extension in prone | Does not centralize lower back and gluteal pain | |
*Sacroiliac Compression test | Positive | Negative |
*Sacroiliac Distraction test | Positive | Negative |
*Thigh Thrust test | Positive | Negative |
*FABER | Negative | Negative |
*Gaenslen’s test | Negative | Negative |
Posterior-anterior springing L2-5 spinous processes | Positive |
Forward head, rounded shoulders. Patient stands with weight shifted on left lower extremity.
Tenderness bilateral erector spinae L2-5 , right PSIS , sacral bases and body of the sacrum , right gluteals extending to posterior thigh. Tenderness noted in right Iliopsoas extending down to inguinal crease. Tenderness in right superior hamstrings , gluteals and adductors.
L1/L2/L3/L4 intact bilaterally. L5/S1 impaired to light touch on right foot, intact on left side.
Patient responded well to physical therapy interventions:
Improvements in Outcomes measures at Discharge:
Modified Oswestry Low Back Pain Disability Questionnaire: 15% Disability.
The Lower Extremity Functional Scale (LEFS): 65/80
The patient could sit for any length of time with ease, could stand > 4 hours; she could ambulate community distances with minimal pain and was able to sleep comfortably through the night. She was no longer limping at the end of her work day.
Idiopathic Pelvic Girdle Pain (PGP) is a broad term for pain in the pelvic girdle and associated structures. What we often see clinically as PGP in relation to the Sacroiliac Joint (SIJ) is the result of a failed load transfer system. Normal alignment of the spine and pelvis and muscle function as it relates to all the muscle groups that attach from above and below to the pelvis, is an essential component of normal load transfer.
Recognizing SIJ dysfunction as a component of PGP helps us to address the big clinical picture of pain and dysfunction. Spinal and pelvic mis-alignment can cause a muscle imbalance in lumbar and pelvic girdle musculature. It alters the optimal length tension relationship of all the muscles involved and may keep some muscles in a perpetual hypertonic state causing pain. Once the bony alignment is restored , the supporting musculoskeletal system can be gradually strengthened and re-educated to maintain this alignment. Correct posture and movement patterns reinforce muscle memory to return to its baseline normal states.
“Sacroiliac Joint Dysfunction is curable with medical and physical therapy interventions. The standard physical therapy (PT) interventions include repetitive exercises, manual joint mobilisation, manipulation, bracing, massage, patient education, aerobic conditioning, general therapeutic exercise and electrotherapeutic modalities such as heat, ultrasound and TENS. Currently, there are no guidelines or an appropriate management plan for this dysfunction, physicians usually refer to it as low back pain only and physiotherapists treat the pain as LBP. However, when it is accurately diagnosed, the appropriate medical intervention or physical therapy can be implemented1.”
Physical therapists play an important role in patient education. Educating patients on the anatomical significance and importance of spinal and pelvic alignment can help improve the patient’s understanding about their diagnosis and can improve compliance with the home exercise program. Communication, setting realistic goals and working together as a team with our patients can go a long way in helping our patients achieve good outcomes.
The author agrees that this case study has limitations in establishing a cause-and-effect relationship and lack of long term follow up. Physical therapists must look at differential diagnoses of PGP in relation to SIJ and lumbo-pelvic pain if their patient’s symptoms fail to normalize or worsen with increasing disability. Presence of possible pelvic floor, hip and lumbar spine dysfunctions must be considered.
Pelvic girdle pain, Sacroiliac joint, SIJ dysfunction, lumbar radiculopathy, low back pain , pelvic rotation, pelvic dysfunction, treatment, therapy, symptoms