Case 4: Mechanical SIJ pain

Question 1

What is SIJ pain?

Answer 1

From the physical examination, 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.

Question 2

Ax priorities of the Pat

Answer 2

1. Observational + Functional
2. AROM lumbar + Overpressure
3. PAIVM and palpation
4. Provocation Tests
5. ASLR test
6. GMax and GMed MMT

Question 3

Ax Observational + Functional Tests/results:

Answer 3

Standing posture
- slumped shoulders, kyphotic
Walking – normal
Single leg stand – slight trendelenburg on L
Single leg squat – difficulty controlling knee valgus on L = pain = 2/10.

Question 4

Ax AROM lumbar + Overpressure

Answer 4

Normal, no pain on overpressure

Question 5

Ax PAIVM and palpation

Answer 5

Negative across all levels
Pain on palpation of L SIJ (4/10 pain) and Piriformis (3/10)

Question 6

Ax Provocation Tests

Answer 6

Positive
- Thigh thrust test
- Distractions
- Compression
- Sacral Thrust Test
- Gaenslens

Question 7

Ax ASLR test

Answer 7

ASLR – slight pain L 2/10, reduced to 0/10 with static TA instructions

Question 8

Ax GMax and GMed MMT + Additional

Answer 8

Glute Max – reduced L = 4/5
Glute Med – reduced L = 3/5. Reduced on R = 4/5

Slight pain on piriformis length test (1/10)
Thomas Test – reduced hip flexor length L compared to R

Question 9

Tx Priorities

Answer 9

1. Advice + Education
2. Increase strength/motor control (to ultimately improve tolerance to standing load)
3. Reduce pain and increase ROM
4. Consider PF exercise to address incontinence

Question 10

Tx - Advice and Education

Answer 10

1. From the PE, I believe you have some pain coming from an area of your back that connects your lower spine to your pelvis called the SIJ: This can be caused by hypermobility or hypomobility of the joint.
2. This pain can also be aggravated by some of the activities after having a baby including sudden and prolonged loading, holding the baby, weakness of key muscles, stress, and sleep can play a part too.
3. Education around what the SIJ is and how its involved in weight bearing.
   - The role of the SIJ is to transfer loads between the spine and lower extremities effectively, simple daily activities such as walking and lifting objects can also cause stress and wear on the joint over time.
4. Strategies to manage pain especially at work. Include key contributing factors and ways to change/avoid these – weakness around key pelvic muscles (Gmed,Gmax), way holding child, lack of sleep, heightened stress, standing time and posture as below, sudden increase in loading – rapid increase in standing hours at work, not exercising as previously – effects general health as well as SIJ.
5. 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.
6. Trial taping or use of SIJ belt.
7. Options re other exercise – reduce length of walks and/or reduce stride length, consider swimming, cycling other types of non-aggravating exercise.
   Postural education – Frequent changes (eg every 15 min) - practice standing with weight through heels – bringing pelvis back under chest, relax knees, feet further apart
8. Advice around even weight bearing (rather than leaning on one leg)
9. Reduce use of NSAID’s as symptoms improve

Question 11

Tx Increase strength/motor control

Answer 11

1. Glute med/max strengthening
   - Crab walks
   - Squats with Theraband
   - Transferring onto one leg slow and controlled (all just options).
   - Glute bridge in supine
2. TA education as this helped with ASLR
   - Instructions on activating TA
   - ie movements in 4-point kneeling exercise or during standing exercises above – starting at a level that the patient is at.
   - Glute kick back with theraband in standing to further rely on TA

Question 12

Tx Pelvic floor exercise initiation

Answer 12

1. Teaching engagement of PF
   - Education on importance of PF for incontinence
   - How PF exercise can be done anywhere

Question 12

Tx Reduce pain and increase ROM

Answer 12

1. Manual therapy, SIJ mobilisations
   - Standing or in side lying , depending on symptoms and irritability
   - MWM of anterior rotation of pelvis in
   - Standing as the patient lifts opposite leg.
2. Massage also considered.

Question 13

What the patient can do

Answer 13

• Education around the importance of standing with weight equally on both legs and through the heels.
• Bring pelvis back underneath your body.
• Regular breaks at work to change position, talk to work about the opportunity to take more breaks in sitting or temporarily taking on an administrative task.
• Consider taking shorter walks or exercise modification towards activities such as swimming or cycling for the short term.