CASE 4 - Left mechanical SIJ pain

Question 1

ASSESMENT PRIORITIES

Answer 1

1. AROM→ Clear lumbar spine/rule out referral
   SIJ Provocation tests
   Functional tasks

Question 2

ASSESMENT PRIORITIES

1. AROM

Answer 2

→ Clear lumbar spine/rule out referral

Question 3

ASSESMENT PRIORITIES

SIJ Provocation tests

Answer 3

• Confirm it is mechanical SIJ pain
• Most effective way to confirm
• Replicate symptoms
• THIGH THRUST, DISTRACTION, Compression, • Sacral PA- Patient Prone, Gaenslens Test

Question 4

5 Provocation tests

Answer 4

Provocation Tests – looking for first 2 or 3/5 to for a positive test result
(positive = reproduction of symptoms)
• Thigh Thrust lying supine with one hip flexed to 90 degrees.
- Therapist stands on opposite side to leg. Pull knee into
adduction to place bottom hand under patient’s sacrum on
one side of SIJ. Bring back to neutral. Use sternum to push
down onto knee. Start with small thrust, if no pain, gradually
- increase pressure asking for pain. Change angle of thrust
(flex/ext/add/abd) to try and find positive test)

• Distraction - Patient in supine, legs extended. Place hands on
ASIS’s, Apply pressure downward – outward. Start with
small amount of force and progress depending on symptoms. If
patient is sensitive over ASIS, use folded towel between hands
and ASIS. Ask patient if symptoms replicated.

• Compression- Side lye. Therapist compresses iliac crest
toward opposite iliac crest. Start with small amount of force
and progress depending on symptoms. Ask patient if
symptoms replicated

• Sacral PA- Patient Prone. Therapist applies a downward
force on PA (spring) using heel hand reinforced with
opposite hand. Check for symptoms on both sides and
centrally, caudally and cranially. Ask patient if symptoms
replicated

• Gaenslens Test- Induces posterior rotation on the bed side
and anterior rotation on the leg off the bed, thus to apply shear
forces on the SIJ. Patient supine – supports leg on bed. Slowly
and carefully lower opposite leg. If patient is comfortable and
symptoms not yet induced, apply downward force on leg off
bed. Ask patient if symptoms replicated.

Question 5

ASSESMENT PRIORITIES

Functional tasks

Answer 5

• standing/gait - What she has pain/trouble with, Functionally relevant
• Holding baby
• Stork test/single leg stance/squat
- Observe for trendelenberg, difficulty shifting weight

Question 6

ASSESMENT PRIORITIES

OTHER ASSESMENTS

Answer 6

4. Gillets and stork test
5. ASLR
   - See if symptoms reduced with compression, TA (indicates treatment)
   - Looks for lack of force closure

Question 7

MANAGEMENT PRIORITIES

Answer 7

1. Advice and Education
   Increase strength/motor control
   reduce pain

Question 8

MANAGEMENT PRIORITIES

1. Advice and Education

Answer 8

• Diagnosis: I believe you have some pain coming from an area of your back that connects your lower spine to your pelvis called the SIJ: Can be caused by hypermobility or hypomobility.
  Prognosis: 90% of patients have a positive outcome to treatment within 6 weeks
  Reasurrance about condition:
  • You haven’t had any significant injuries to your back.
  • Your back is a strong and robust structure, in particulary the SIJ is a very stable, allowing only gets small bits of movement.
  • The pain you are experiencing doesn’t equate to damage to the tissue.

Work: strategies to manage pain especially at work. Regular breaks at work to change position – possibly talk to work about being able to take more breaks into sitting – or consider administrative tasks temporarily.
- TA activation occasionally when standing (as it relieves symptoms)
Better prognosis and long term outcomes (get stats ect.)

Postural/baby handling education – practice standing with weight through heels – bringing pelvis back under body. Avoid hip hanging. Try to keep weight even through both feet when standing. Postural education on how to hold baby

• Explain that this can be contributing to pain and putting excess weight through one side. Explain that this is why we need to strengthen
• Improves patient understanding and knowledge of contributing factors and aims for treatment. Patient will be much more aware and so have active role in treatment
• Activity modification → reduce load/volume of walks/exercise
• Consider low load activities eg cycling, swimming
• Important to maintain exercise and also will begin graded exposure

Question 9

MANAGEMENT PRIORITIES

Increase strength/motor control

Answer 9

→ Glute Med to decrease trendelendburg and aid force closure, decrease pain, assist load transfer
Standing: squat with TB → progress to single leg

Question 10

MANAGEMENT PRIORITIES

3. Reduce pain and increase ROM

Answer 10

a. Consider manual therapy - sacral mobilisation in side lying (only if acute symptoms). NWB.
i. What to say to patient (example previously)
b. MET techniques to reduce pain in anterior rotation.
c. MWM of anterior rotation of pelvis in standing as the patient lifts opposite leg. Or can start with ant rotation in side lye
d. Start stretches of hip flexor if tolerated.
e. Massage also considered.
f. Address thoracic mobility (manual therapy, stretches).
g. Taping could be considered.