Idiopathic Pelvic Girdle Pain (PGP) in relation to the Sacroiliac Joint (SIJ):
Clinical implications

Idiopathic Pelvic Girdle Pain (PGP) in relation to the Sacroiliac Joint (SIJ): Clinical implications

Sample Case Study

Abstract

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).

Author

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.

Introduction

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.

History & Patient Characteristics

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”.

Examination Findings

Subjective
8/10 right sided low back pain and right gluteal pain on the Visual Analog Scale (VAS). Difficulty getting in and out of the car. Difficulty standing for long periods of time at work. Difficulty finding a comfortable sitting or sleeping position. Limps at the end of the workday. Works part time, has a hour plus commute each way to work 3 days/ week which she states “is stressful”.

Past Medical History

Lumbar radiculopathy (onset 5 yr. ago) and plantar fasciitis (onset 8 yr. ago) – residual numbness in 3rd, 4th and 5th toes of right foot. Borderline hypertension. GERD. Irritable Bowel Syndrome. One emergency c-section, one planned c-section.

Outcome Measures

Modified Oswestry Low Back Pain Disability Questionnaire: 62% Disability.

The Lower Extremity Functional Scale (LEFS): 40/80

Objective

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

Positional dysfunctions

Positive Extended-Rotated -Side bent Right (ERSR) at L3-5 levels. Leg length discrepancy – Right ilium rotated forward. Sacral torsion: Right on Right forward Sacral torsion.

Observation

Forward head, rounded shoulders. Patient stands with weight shifted on left lower extremity.

Palpation

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.

Dermatomes

L1/L2/L3/L4 intact bilaterally. L5/S1 impaired to light touch on right foot, intact on left side.

Range of Motion (ROM)

Lumbar AROM= full flexion, moderately limited extension, bilateral rotation WFL. Hip AROM= Right hip flexion, extension mildly limited, internal and external rotation moderately limited. Left hip WFL. Knee AROM: WFL bilaterally. Ankle AROM: Dorsiflexion and Eversion moderately limited bilaterally, Plantarflexion and Inversion WFL.

Manual Muscle Test (MMT)

Right hip flexion: 4-/5, extension: 4-/5, abduction: 4/5, adduction 3-/5. Left Hip flexion: 4+/5, extension: 4/5 ,abduction, 4/5,adduction: 4-/5. Bilateral knee flexion/ extension: 4+/5. Right ankle Dorsiflexion : 3-/5, Plantarflexion: 4-/5, Inversion/ Eversion: 4-/5. Left ankle MMT throughout 4/5 except DF: 3-/5. Great toe extension 3-/5 on right , 4/5 on left.

Gait

Antalgic gait, decreased stance time on right foot.

Clinical Impression

Loss of lumbar extension, ROM deficits in right hip and right ankle. MMT deficits in right hip and ankle. Lumbar, pelvic and sacral mis-alignment. Residual sensory deficits in right foot. Near constant pain mildly responsive to NSAIDS. Poor tolerance for extended periods of sitting and standing. Difficulty finding comfortable position for sleeping. Outcomes measures: Deficits noted on both Modified Oswestry Low Back Pain Disability Questionnaire and Lower Extremity Functional Scale.

Interventions

Patient was seen for a total of 15 visits. Pain levels decreased from 8/10 t0 5/10 on the VAS scale by the 5th visit and decreased to 0-2/10 by 15th visit.
Manual correction of positional dysfunctions:
Manual release of thoracolumbar fascia , STM to right Erector spinae ,Ilipsos Gluteals, piriformis and adductors Long axis distraction of the right leg PROM and AAROM of right hip in all planes, repeated on left side. Right ankle mobilization in all planes. Manual stretching of hamstrings and piriformis muscles in varying degrees of hip flexion and rotation. Home Exercise Program included patient education on posture, body mechanics, breathing and proper sitting and standing posture. Patient was also educated on sleeping positions that aggravate SIJ and LBP. Patient was educated on self-correction of Right anterior rotated Ilium and self-correction of Lumbar facet mis-alignment using a doorway. She was instructed on checking her lumbar and pelvic alignment everyday. Core stabilization exercises. Functional movements and exercises. Education on pain and stress management

Outcomes

Patient responded well to physical therapy interventions:

Improved postural awareness Able to identify aggravating positions and activities and adapt Able to sit, stand and walk pain free Able to sleep undisturbed at night Able to get in and out of the car pain free

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.

Discussion

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.

References

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Keywords

Pelvic girdle pain, Sacroiliac joint, SIJ dysfunction, lumbar radiculopathy, low back pain , pelvic rotation, pelvic dysfunction, treatment, therapy, symptoms