Examination of the Pelvis and Sacroiliac Joint

Question 1

What is Sacro Iliac Joint (SIJ) Dysfunction?

Answer 1

SIJ Dysfunction is associated with pain that arises from the sacroiliac joint and is caused by a number of causes. May be due to a asymmetry of stability, inflammation, intrinsic or extrinsic dysfunction to the joint, or arthritis.

Question 2

Define Pelvic Girdle Pain (PGP).

Answer 2

• PGP generally arises in relation to pregnancy, trauma, osteo-arthrosis and arthritis.
• Pain is experienced between the posterior iliac crest and gluteal fold, particularly in the vicinity of the SIJ.
• Pain may radiate in the posterior thigh and can also occur in conjunction with/or separately in the symphysis.
• Diagnosis of PGP can be reached after exclusion of
lumbar causes.

Question 3

Prevalence of SIJ pain vs. Pelvic girdle pain?

Answer 3

• SIJ Pain (13-30% of those with chronic low back pain).
• Pelvic Girdle Pain (50% if pregnant or recently pregnant).

• PGP and SIJ pain/dys are syndromes – Syndromes and diagnoses are two different things.

Question 4

Como confirmar se existe uma SIJ dysfunction?

Answer 4

• SIJ Dysfunction can’t be confirmed by clinical examination;
• Fluroscopically guided injection for confirmation
is not perfect and it’s not wholly accurate;
• Confirmation requires a sophisticated tool to measure the incremental movements associated with SIJ dysfunction (any variety).

Question 5

A SIJ pode ser a origem da dor?

Answer 5

Most of the mechanoreceptors in the SIJ have a nociceptive function which suggests that the sacroiliac joint may be a source of lower back pain and has little proprioceptive function.

SIJ satisfies criteria to quality as a pain generator: (1) It has a nerve supply; (2) It is susceptible to disease or injuries known to be painful (e.g., infection, trauma, malignancy, etc); (3) It is capable of causing pain that is clinically detectable.

Question 6

Quais são os principais fatores de risco para a dor sacroilíaca?

Answer 6

• True and apparent leg length discrepancy
• Gait abnormalities
• Prolonged vigorous exercise
• Scoliosis.

Question 7

Qual é a apresentação clínica da dor SIJ?

Answer 7

• Can present as low back pain, sacral pain, pelvic pain, or gluteal pain
• Numbness, popping, clicking, or groin pain can occur
• Pain usually not above the beltline
• Unilateral pain superior bilateral pain (4:1)
• History of trauma in 44-58% of individuals with SIJ pain

Question 8

Refere fatores que podem estar associados a pelvic girdle pain?

Answer 8

• Typically during or post pregnancy;
• Involves asymmetric laxity of the SIJ or pubic symphysis involvement (This leads to constant overload of the pelvic ligaments and consequential instability);
• 15% greater symphyseal width (sup 10mm);
• Poor muscular control (Increased muscle activity with less force production);
• “It’s not just the hormones”.

Question 9

Define chronic pelvic pain.

Answer 9

Chronic pelvic pain is defined as the presence of pain in the pelvic girdle region for over a 6-month period and can arise from the gynecologic, urologic, gastrointestinal, and musculoskeletal systems.

Question 10

Denomina algumas condições de diagnóstico diferencial, relativamente à SIJ pain.

Answer 10

1 Pyriformis syndrome; 2 Hip joint pathology; 3 Discogenic pain; 4 Zygapophysial joint pain; 5 Rheumatoid arthritis; 6 Ankylosing spondylitis; 7 Myofacial spondylitis; 8 Myofascial pain; 9 Lateral trochanteric bursitis; 10 Malignancy; 11 Visceral referrad pain; 12 Radiculopathy.

Question 11

Quais são os fatores de risco para a pelvic girdle pain?

Answer 11

• History of Previous low back pain
• History of Trauma to the pelvis
• History of current or recent (n inferior 2 years) pregnancy
• High Work Load
• Pluripara (2 or more pregnancies with full term fetus).

Question 12

Qual é a apresentação clínica da pelvic girdle pain (PGP)?

Answer 12

• Pain localized to the pelvic girdle either posteriorly close to the SIJ or anteriorly near pubic symphysis
• Peak onset 3rd trimester
• Pain with sit to stand
• Pain with coughing, sneezing
• Altered gait pattern (slower velocity)
• Catching or clicking with hip flexion
• Pubic symphysis tenderness.

Question 13

A fluoroscopically guided joint block is the closest we come to correctly diagnosing SIJ syndrome. What degree of pain reduction is needed to confirm the diagnosis?

Answer 13

80% pain reduction is required for positive confirmation of SIJ as the pain generator.

Question 14

Which of the following is the most accurate statement with respect to pelvic girdle pain?

1) Women typically begin to experience pelvic girdle pain in their 2nd trimester;
2) Women with pelvic girdle pain will often complain of pubic symphysis tenderness;
3) Women with pelvic girdle pain typically report catching or clicking with hip external rotation.

Answer 14

2 is correct - Women with pelvic girdle pain typically report pain either posteriorly close to the SI or anteriorly near the pubic symphysis.

Question 15

Which of the following statements is true with regards to the SIJ?

1) It has a nerve supply;
2) It is susceptible to disease/injury known to be painful;
3) It is capable of causing pain that is clinically detectable;
4) All of the above.

Answer 15

4 is correct. SIJ satisfies criteria as a pain generator because it has a nerve supply, it is susceptible to disease or injury known to be painful, and it is capable of causing pain that is clinically detectable.

Question 16

Ms. B reports she initially felt pain after moving a patient up in the bed. Why the SIJ is at risk as a result of Ms. B’s movement?

Answer 16

The sacrum is 2x as susceptible to axial torsion overloading as compared to the lumbar spine. It is most likely that Ms. B experienced a position of axial torsion while in standing and twisting to move the patient.

Question 17

Onde incide geralmente a dor da SIJ?

Answer 17

• Pain from the SIJ is generally located in the gluteal region (94%);
• Referred pain may be present in lower lumbar (72%), groin (14%), upper lumbar region (6%), or abdomen (2%);
• 28% of patients report pain in the lower limb and 12% report pain in the foot.

Question 18

Porque é importante perceber a natureza da dor e sintomas?

Answer 18

• It is important to identify all areas of pain to help rule in/rule out specific hypotheses – A typical patient will report pain approximately 3x10cm just inferior to the posterior iliac spine; Typically unilateral; PGP presents posteriorly or anteriorly near the pubic symphysis.
• Identifying pain type helps to further narrow down hypothesis when considering differential diagnosis – PGP has been described as stabbing, dull, shooting, burning.

Question 19

Quais são os fatores agravantes – What activities make your symptoms worse?

Answer 19

• Prolonged standing, walking
• Changing positions
• Coughing, sneezing
• Pain with single leg stance.

Question 20

Que direções nos dá a pain history?

Answer 20

• Pain while rising from sitting is positively associated with both sacroiliac pain and discogenic pain, but negatively associated zygopophyseal pain.
• Relief during immediate sitting is strongly suggestive of spinal stenosis (Sn 0.46; Sp 0.93).

Question 21

Exemplifica questões que podem ajudar a decartar problemas, como red flags.

Answer 21

• Do you notice any feelings of numbness or pins and needles bilaterally?
• Night Pain?
• Have you suffered any recent weight loss?
• Do you ever feel as though you are stumbling while walking?
• Prior history of cancer?
• Have you suffered any recent bowel/bladder changes?
• Do you suffer from any pins/needle like feelings in the inner groin area?

Question 22

Immediate relief of symptoms when sitting is a likely symptom of SIJ/pelvic pain?

Answer 22

No, immediate relief of symptoms when sitting is strongly suggestive of spinal stenosis.

Question 23

What percentage of patients with SIJ pain report a history of trauma?

Answer 23

A history of trauma is reported in 44-58% of individuals with SIJ pain.

Question 24

Exemplifica 3 outcomes measures que podem ser usados in patients with SIJ/pelvic girdle pain.

Answer 24

• The pelvic girdle questionnaire is commonly used to find out how problematic carrying out certain activities is because of pelvic girdle pain.
• The Oswestry Disability index is typically used to qualify disability for low back pain, and is known to be used for patients with SIJ/pelvic girdle pain.
• The Roland Morris Disability questionnaire.

Question 25

Se o utente se queixa de sintomas referidos, o que devemos fazer?

Answer 25

You collect data to determine if peripheral signs and symptoms are likely due to a neurological lesion (diff. DX) and grossly where along the path of a nerve the lesion is:
– myelopathy (brain or spinal cord/upper motor neuron)
– radiculopathy (nerve root)
– plexopathy (plexus)
– neuropathy (peripheral nerve).

Question 26

Que sinister disorders podemos considerar?

Answer 26

• Non-mechanical conditions such as ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome, systemic lupus erythematosus, Sjoegren’s syndrome, gout, Paget’s disease, tuberculosis, and various bacterial infections.
• Look for skin lesions or conjunctivitis.
• In the absence of a traumatic history, consider laboratory testing for assistance in diagnosis of these afflictions.

Question 27

Quais são os fatores da história clínica que nos podem levar a desconfiar de espondilite anquilosante?

Answer 27

– age at onset inf 40 (Sn 1.00; Sp 0.07);
– pain not relieved by supine (Sn 0.80; Sp 0.49);
– morning back stiffness (Sn 0.64; Sp 0.59);
– pain duration sup 3 months (Sn 0.71; Sp 0.54);
– 4 of 5 questions above positive also improved by exercise (Sn 0.23; Sp 0.82).

+Lr = 1,27

Question 28

Como podemos rule out fraturas pélvicas?

Answer 28

Achados negativos em:
• Inflammation (sacral ala fracture)
• Pain with Hip ROM
• Pain during rectal examination
• Pain during compression
• + Pubic Percussion Test (LR+ = 9 to 313)

Question 29

Que teste nos ajuda a descartar pelvic ring fracture?

Answer 29

Hip flexion test to rule out pelvic ring fracture – Patient lies supine, performs ASLR, positive test is reproduction of pain or inability to raise the leg (Sn 90; Sp 95).

Question 30

Quais os achados no exame clínico que nos permitem concluir sobre uma possível fratura do sacro?

Answer 30

Clinical Examination (CE) findings age (OR, 1.025), hip pain (OR, 4.971) internal rotation of the leg (OR, 4.880), tenderness to palpation over the sacrum (OR, 2.297) tenderness over the right or left hip (OR, 3.626) diffuse pain throughout the pelvis (OR, 16.445).

CE (SN 96.4; SP 50.25); X-ray (SN 79.2; SP 99.7).

Question 31

How to rule out the hip?

Answer 31

• Passive hip flexion
• Passive internal rotation
• Labral tests with axial and IR overpressure.

Se estes movimentos não despertarem dor, podemos excluir o quadril como causa primária dos problemas.

Question 32

Quais os tipos de movimentos que podemos testar no exame específico da pélvis?

Answer 32

• Nutation - Patient’s affected leg is driven into flexion creating nutation.
• Couternutation - Patient’s affected leg is driven into extension creating counternutation.
• Passive rotation asymmetry is positively associated with sacroiliac dysfunction.
• Palpation tests.
• Provocation tests (Laslett’s Cluster).

Question 33

A palpação é realmente útil na avaliação?

Answer 33

• Useful for extraarticular disorders;
• Useful to implicate the long dorsal ligament
• There is a preponderance of evidence that for the lay clinician, the reliability and diagnostic value of movement assessment techniques of the SIJ are fairly low.

Question 34

Quais os testes palpatórios que são úteis na avaliação?

Answer 34

• Stork Test
• Public Symphysis Palpation
• Long dorsal ligament

• Other palpation tests aren’t useful (Gillet’s Test; Long-sit Test; Standing Flexion Test; ASIS and PSIS Asymmetry tests).

Question 35

Quais são os testes provocativos de Laslett? Para que se utilizam?

Answer 35

• SI Compression Test;
• SIJ Gapping;
• Sacral Thrust;
• Thigh Thrust;
• Gaenslen’s Test.

This tests are used to determine patients with a sacroiliac dysfunction – Using a combination of three of five tests, the positive likelihood ratio improved to 4.16.

Question 36

Como aplicar o SI Compression Test?

Answer 36

1 - Lie patient on side or supine. 2 - Press downward with max force over iliac crest. 3 - Hold 30 seconds. 4 - Bounce force at end of 30 seconds.

Question 37

Descreve o SIJ Gapping test.

Answer 37

• 1. Lie patient on supine.
• 2. Cross arms and apply force over ASIS.
• 3. Apply for 30 seconds.
• 4. Bounce force at end of 30 seconds.

Question 38

How to apply Sacral Thrust test?

Answer 38

Paciente em decúbito ventral:
1. Apply force on S3 spinous process.
2. Force should be 3 to 5 hard thrusts.
Reprodution of symptoms is considered a positive test.

Question 39

Quais os passos para o Thigh Thrust test?

Answer 39

• 1. Patient lies on back.
• 2. Place hand under sacrum.
• 3. Pull thigh up to 90 degrees and press downward.
• 4. Hold for 30 seconds.
• 5. Bounce force at end of hold.

Question 40

How to perform Gaenslen’s Test?

Answer 40

• 1. Place patient is Thomas position (e na ponta da marquesa).
• 2. Push up on flexed thigh and down on extended thigh.
• 3. Perform 3 to 5 torsions.

Question 41

Qual poderá ser a melhor combinação para os testes de Laslett?

Answer 41

• Thigh thrust, distraction, sacral thrust, and compression tests - 2 of 4 (SN 88; Sp 78).
• Distraction test, compression test, thigh thrust, Patrick sign (FABER test) - 3 of 5 (Sn 85; Sp 79).
• Distraction, thigh thrust, Gaenslen test, Compression, and sacral thrust - 3 of 5 (Sn 91; Sp 87).
• Active SLR, Gaenslen, or Thigh Thrust - 1 of 3 (Sn 88; Sp 66).
• ASLR, Lunge, or Thigh Thrust - 1 of 3 (Sn 94; Sp 66).

Question 42

Descreve o Stork test.

Answer 42

• With patient standing, examiner palpates the S2 spinous process with one thumb and the PSIS with the other and asks patient to flex the hip and knee on the side being tested. Positive if the PSIS fails to move posteroinferiorly with respect to S2.
• The Stork Test and ActiveSLR measure the presence of a pelvic ring instability, but most notably, poor neuromuscular control during loading.

Question 43

O que se deve fazer ao testar o ActiveSLR?

Answer 43

O utente realiza a elevação da perna ativamente. Se referir alguma instabilidade ou até mesmo dor na zona pélvica, aplica-se compressão nos ilíacos. O teste é positivo se a dificuldade diminuir com essa estabilização pélvica.

Question 44

Que achado clínico tem sido identificado comummente à lombalgia, dor sacroilíaca e dor pélvica pós-parto?

Answer 44

Alteration in the onset and timing of feed-forward muscular response of the TrA (transversus abdominus) has been identified in patients suffering from low back pain, SIJ pain, and postpartum pelvic pain.

Goal here is to assess motor control strategies for force
closure of the pelvis and support to the thoracolumbar
spine during general body movements, transition, and
functional activities. Includes TrA, diaphragmatic breathing, utilization of balanced activation between abdominal muscles and trunk extensors, and observation of aberrant movement of spine.

Question 45

How do we test the transversus abdominus?

Answer 45

• Patient in ventral decubitus.
• Place Stabilizer under abdomen with navel in center and distal edge of pad in line with right and left ASIS’s.
• Inflate pad to 70 mmHg and allow to stabilize.
• Instructions for muscle contraction during formal test is identical as 4-point kneeling (draw-in maneuver).
• Successful test reduces the pressure by 4-10 mmHg and maintains hold for 10 s.
• If patient can reduce pressure during test, then holding capacity is tested via 10-s holds up to 10 repeats.

Question 46

Como testar Segmental Lumbar Multifidus?

Answer 46

• Patient in ventral decubitus.
• Test begins w/ palpation of muscle at each segment adjacent to spinous process.
• Compare side-to-side and above and below for loss of muscle consistency.
• Fingers are gently sunk into muscle belly.
• Instructions for breathing same for TrA test.
• Patient is asked to gently and slowly swell out the muscle into the fingers, then resume normal breathing.
• Tester assesses if tonic holding is achievable via palpation.

Question 47

All patients should be triaged for potential red flags. What can be a concerning finding indicative for a pelvic fracture?

Answer 47

Inflammation, pain with hip ROM, pain during rectal examination, pain during compression, and positive pubic percussion test are all signs for pelvic fractures.

Question 48

Which if the following is NOT included in Laslett’s pain provocation cluster? Thigh thrust; Lunge; Gaenslen’s test or Sacral Thrust?

Answer 48

Lunge is included in Cook’s cluster. Laslett’s cluster includes Distraction or Gapping, thigh thrust, gaenslen’s, Compression, and Sacral thrust.

Question 49

Which test is most appropriate when considering pelvic ring instability?

Answer 49

Active straight leg raise - ASLR will be positive when compression around the pelvis by the therapist decreases patient symptoms when performing the active straight leg raise.

Question 50

Reproduction of symptoms during lumbar range of motion typically implicates the lumbar spine. True or false?

Answer 50

This is correct, it is important to ALWAYS rule out the lumbar spine first before proceeding with a SIJ/pelvic examination.

Question 51

Quais são os 5 diferentes sistemas de classificação da dor da cintura pélvica? E a classificação é fiável?

Answer 51

• One Sided SIJ Syndrome (5.5%)
• Symphysiolysis (2.3%)
• Pelvic Girdle Pain Syndrome (6%)
• Double Sided SIJ Syndrome (6.3%)
• Mixed (1.6%)
• Reliability of a Pelvic Pain Classification System – Kappa = .81
• Begin by “ruling out” of lumbar spine to isolate symptoms; use appropriate test and measures, and location(s) of pain.

Question 52

A que se pensa estar associado o one sided SIJ syndrome?

Answer 52

• May be associated with asymmetric stabilization between the two SIJ joints or trauma/degeneration between innominates.
• Typically, when tested using provocation tests differences will be noted on each side, specifically if the test or movement provokes in the direction of dysfunction.
• Symptoms localized to posterior pelvic girdle and unilateral SIJ.

Question 53

O que é a symphysiolysis?

Answer 53

• Pain in the anterior pelvic girdle and pubic symphysis. With an incidence of 2.3% of pregnant women it’s the lowest of the 5 classifications of pelvic girdle pain syndrome.
• Typically, pain disappears within a month after delivery however, the pain may persist up to six months after delivery.

Question 54

Qual o prognóstico de recuperação da pelvic girdle syndrome?

Answer 54

• Combined stabilization loss of the SIJ, low back and pelvis joints.
• The recovery rate for pelvic girdle syndrome tends to be poorer when compared to the other 4 classifications with many patients reporting pain up to two years after the onset of this syndrome during pregnancy.

Question 55

A que alterações corporais tende a estar associada a double sided SIJ syndrome?

Answer 55

• Double sided SIJ syndrome is commonly associated with stability loss and may be associated with hormone related changes.
• Symptoms of the posterior pelvic girdle and
bilateral SIJ
• Generally, this dysfunction is self resolving and
tends to be isolated to the time of pregnancy.

Question 56

De que resulta da mixed syndrome?

Answer 56

• Mixed models may be associated with various forms of instability, including both SIJ and pubic symphysis pain.
• Mixed models are most likely a reflection of instability, but may be a result of neuromuscular dysfunction as well.