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PHTY2220 > L8: Differential Diagnosis and Disorders of the Pelvis > Flashcards

L8: Differential Diagnosis and Disorders of the Pelvis Flashcards

1
Q

What are the 4 proposed impairments of SIJ?

A
  1. Mechanical
  2. Inflammatory
  3. Intra-articular
  4. Extra-articular
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2
Q

Why is it important to differentiate between mechanical and inflammatory SIJ pain?

A

Physios treat mechanical SIJ pain, not so much inflammatory

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3
Q

What are the 8 proposed causes of SIJ pain?

A
  1. Hypermobility
  2. hypomobility
  3. Trauma
  4. degenerative arthritis
  5. inflammatory arthropathy (sacroiliitis)
  6. infection
  7. ligament strain
  8. Stress fractures
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4
Q

_____ (systemic/local) inflammatory conditions can manifest as SIJ pain. (e.g.________)

A

systemic; ankylosing spondylitis

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5
Q

There are _____ (specific/non-specific) causes of SIJ inflammatory pain.

A

Specific

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6
Q

What are the 4 most common inflammatory SIJ conditions?

A
  1. Ankylosing spondylitis (AS)
  2. Reiter’s syndrome (reactive arthritis)
  3. Inflammatory bowel disease
  4. RA
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7
Q

What are the 4 proposed mechanisms for mechanical SIJ pain?

A
  1. Nociception from ligaments or gluteal origins
  2. Irritation due to over-load (tendons, ligaments, joint) (Eg. Start new activity)
  3. Excessive articular compression
    • Fusion (AS)
    • Capsular fibrosis
    • Dysfunction or excessive bracing of global myofascial system
  4. Insufficient articular compression?? (Eg. in pregnancy –> due to the change in hormones)
    • Ligamentous laxity
    • Lack of ability of local myofascial system to provide stability
    • This is a disputed area in research
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8
Q

What are the 8 factors suggestive of a loss of force closure of SIJ?

A
  1. Habitual passive postures (e.g. slump sit, sway standing, Trendelenburg may lead to overload of SIJ structures.)
  2. Excessive lateral pelvic and lower trunk rotation with limb loading
  3. Poor loading strategies in WB
  4. Abdominal bracing strategies
  5. Poor gluteal function
  6. Local muscle weakness: Inability to lift pelvic floor and initiate a low abdominal wall contraction with controlled respiration (NWB & WB)
  7. Compromised urinary continence
  8. +ve active SLR
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9
Q

What is an effect of mechanical SIJ pain?

A

Mechanical pain - worse with activities, better with rest.

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10
Q

What are 4 effects of inflammatory SIJ pain?

A
  1. Can mimic mechanical conditions
  2. Carefully consider history and symptom behaviour (interview findings)
  3. Local symptoms: Joint stiffness, morning stiffness and pain, swelling, multiple joints affected
  4. Systematic symptoms: Irritable Bowel, eye problems, skin changes, fever, fatigue
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11
Q

What is the most common symptom of SIJ pain?

A

Unilateral pain below L5 at fortin or tuber area (ischial tuberosity).

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12
Q

What are 5 other symptoms of SIJ pain?

A
  1. Stiffness and pain with walking
  2. Pain opposite side with walking
  3. Pain same side with walking
  4. Pain with sit to stand or other loading activities
  5. Coccydynia: SIJ pain referred to coccyx
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13
Q

What are 3 steps in the diagnosis of SIJ pain?

A
  1. Ruling out the lumbar spine
    1. Symptoms below L5
    2. No pain in Lumbar Spine with AROM (with overpressure)
    3. PAIVMs do not replicate SIJ symptoms
  2. At least 3 out of 5 SIJ provocation tests +ve OR first 2 tests +ve
  3. May or may not include +ve Active SLR test
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14
Q

What are 2 reasons to rule out the lumbar spine first?

A
  1. Most buttock pain is referred somatic pain from the lumbar spine (very common)
  2. Best to rule out the most common thing (back pain) first before moving to SIJ Go into back tests before pelvic test
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15
Q

SIJ provocative test have a _____ (high/low) validity.

A

high

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16
Q

______ pain is a common clinical presentation particularly in individuals with associated back pain.

A

Buttock

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17
Q

The most common cause of buttock pain is _______ referred pain from ______.

A

somatic/neuropathic; lower back.

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18
Q

The second most common cause of buttock pain is referred pain from____.

A

SIJ

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19
Q

Must rule out referred pain from __ and ___ using LBP tests and SIJ provocation tests, before examining buttock area.

A

Lx; SIJ

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20
Q

What are 6 other causes of buttock pain?

A
  1. Ischial Tuberosity (bursitis, tendinopathy)
  2. Hip referred pain
  3. Piriformis (deep gluteal pain): Piriformis pain is an old term - avoid.
  4. Trochanteric pain (bursitis, tendinopathy)
  5. Avulsions and apophyseal injuries
  6. Muscle trigger points: Palpation to examine muscle groups.
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21
Q

“_______” is more often used to describe the buttock pain caused by the compromise of _____ nerve, which may become the source of_____, or have issue with ____.

A

Deep gluteal syndrome; sciatic; nociception; conduction

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22
Q

Why is there a controversial diagnosis with piriformis syndrome?

A

Over-diagnosed

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23
Q

Buttock pain is more likely caused by somatic referred pain from _____ spine.

A

lumbar

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24
Q

What is suggestive of a positive diagnosis in piriformis syndrome/deep gluteal syndrome?

A

Lengthened piriformis (Ober’s Test) replicating pain & neural symptoms - neural compression (decreased nerve potential).

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25
Q

____ and ___ can identify enlarged piriformis muscle.

A

MRI; CT

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26
Q

When is pirformis syndrome diagnosed?

A

Once back pain tests, SIJ pain have already been assessed and been -ve

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27
Q

Piriformis syndrome is often referred to as a “diagnosis of _____”

A

exclusion

28
Q

What are 4 signs and symptoms of piriformis syndrome?

A
  1. Ruling out other more likely causes (referral from Lumbar Spine)
  2. Palpable tenderness of the Piriformis muscle with or without production of distal symptoms
  3. Pain reproduced with piriformis length test
  4. Positive Pace sign (pain reproduced with resisted external rotation and abduction of the affected hip)
29
Q

What are 2 other physical tests for piriformis syndrome?

A
  1. assessing other key weight bearing muscles (glute max, med)
  2. other relevant length tests.
30
Q

Where can you palpate piriformis?

A

GT and edge of sacrum = half way through the 2 points

31
Q

What is the other name of pregnancy related pelvic girdle pain (PPGP)?

A

symphysis pubis dysfunction (SPD)

32
Q

What are 3 factors that increase the risk of PPGP?

A
  1. a history of lower back or pelvic girdle pain
  2. having PPGP in a previous pregnancy
  3. a physically demanding job
33
Q

Lumbo-pelvic pain is common during pregnancy with a prevalence described variously as ranging from ____% to ___ %.

A

50% to 70%

34
Q

14-22% of pregnant women have ____ (serious/mild) PGP. 5-8% of them have problems with ____(mild/severe) pain and disability

A

serious; severe

35
Q

___% of women postpartum have serious PPGP.

A

7%

36
Q

What are the 2 treatment for mild PPGP?

A
  1. Loading
  2. strengthening
37
Q

How common is leg length discrepancies?

A

Very common ≤95% people have some LLD. Average LLD is ~5mm, with the right leg commonly being shorter than the left

38
Q

Is there any correlation between LLD and common MSK conditions?

A

No correlation between LLD and common MSK conditions, including lateral hip pain and chronic low back pain and scoliosis.

39
Q

What is minor LLD? How does it alter kinematics?

A

(<2 cm) do not alter the kinematics or kinetics of gait.

Minor LLD are not clinically relevant as the body can tolerate. LLD >1cm may have a greater prevalence of knee OA.

40
Q

What is major LLD? How does it alter kinematics?

A

LLD >2cm causes pelvic obliquity in the frontal plane (Trendenlenburg/pelvic drop), and lumbar scoliosis with convexity towards the shorter side

Larger LLD = more mechanical work

Pain related to LLD (>2cm) occurs through excessive ground reaction forces, mainly in the shorter limb.

41
Q

How can scoliosis be observed and monitored in children/teenagers?

A

x rays

42
Q

What is the gold standard for measure leg length?

A

Full-length standing AP computed radiograph (teleoroentgenogram) +/- CT scanogram

43
Q

What is the apparent leg length?

A

from umbilicus to medial malleolus

44
Q

What is the true leg length?

A

from ASIS to medial malleolus

45
Q

What are 3 differences due to potential errors with tape measurements?

A
  1. leg circumference
  2. angular deformities
  3. difficulty in palpating bony landmarks.
46
Q

What are 19 MSK causes of pelvic/buttock pain?

A
  1. Hernias (inquinal, femoral, umbilical, incisional, spigelian)
  2. Nerve entrapments are rare, but present as deep pelvic pain. Common in women’s health.
  3. Nerve entrapment (neuritis/neuralgia): Pudendal, ilioinguinal, genitofemoral, inferior clunal.
  4. Coccydynia
  5. Pubic Symphysis pain
  6. SIJ pain
  7. Hip OA
  8. Iliopsoas tendinopathy
  9. Acetabular Labral tears
  10. Femoral Acetabular Impingement
  11. Somatic referral from non-specific low back pain
  12. Lumbar Radiculopathy
  13. Symptomatic spondylolisthesis
  14. Piriformis pain
  15. Rectus Abdominis
  16. Pelvic Floor myofascial pain
  17. Rheumatoid Arthritis
  18. Ankylosing Spondylosis
  19. Reiters Syndrome
47
Q

What are 6 gynaecological causes of pelvic/buttock pain?

A
  1. Endometriosis
  2. Adhesions (chronic PID)
  3. Leiomyomata (fibroids)
  4. Adenomyosis
  5. Pelvic congestion syndrome
  6. Adnexal masses

Present as Visceral/somatic referred pain around pelvic/abdomen

Non-mechanical pain

48
Q

What are 8 non-gynaecological causes of pelvic/buttock pain?

A

Gastrointestinal

  1. Irritable bowel syndrome
  2. Chronic appendicitis
  3. Inflammatory bowel disease (Crohn’s)
  4. Diverticulosis
  5. Meckel’s diverticulum

Urologic

  1. Unstable bladder (detrusor instability)
  2. Urethral syndrome (chronic urethritis)
  3. Interstitial cystitis
49
Q

What are 6 psychosocial risk factors of pelvic/buttock pain?

A

Psychosocial risk factors are especially important with nonMSK pelvic pain.

  1. History of abuse (e.g. sexual, physical, verbal/emotional) is very common in chronic pelvic pain.
  2. History of anxiety, depression, psychological disorders
  3. Eating disorders, body issues
  4. Sexual issues
  5. Over-training
  6. Other psychosocial risk factors related to lumbar conditions (e.g. work, home, stress, anxiety, fear-avoidance)
50
Q

How common is chronic pelvic pain?

A

≤15-25% people have chronic pelvic pain

51
Q

The most common cause of chronic pelvic pain when visceral problems have been ruled out is__________

A

pelvic floor myofascial pain syndrome (non-mechanical symptoms)

52
Q

What can pelvic floor myofascial pain syndrome also present as?

A

coccydynia

53
Q

Pelvic floor myofascial pain syndrome has _____ (mechanical/non-mechanical) symptoms and ____ (generalised/localised) pain on pelvic floor.

A

non-mechanical; localised

54
Q

What are the 5 causes of Pubic Symphysis Pain?

A
  1. Degeneration or tears of the articular disc, most common in sports that repetitively torsions or shears the pubic symphysis with high loads.
  2. High-energy trauma to pubic symphysis, particularly crush and side-impact injuries.
  3. Low-energy overuse
  4. Isolated muscle or tendon injuries that cause insufficiency force closure - risk of developing pubic pain
  5. Parturition & pre-natal
55
Q

The anatomy of pubic symphysis is similar to IVD, with a central disc of ______ that cushions against ______(compressive/tensile/shearing) loads, provides shock absorption and contributes to passive ______.

A

fibrocartilage; compressive; stabilisation

56
Q

Why is ‘Osteitis pubis’ a problematic term?

A

lacks an agreed definition or a specific underlying pathology - not agreed whether it is inflammatory.

57
Q

What are 5 steps in the diagnosis of pubic symphysis pain?

A
  1. Rule out lumbar referred pain first!
  2. Tender/painful pubic symphysis: Ask patient to press on pubis.
  3. +ve adductor squeeze test
  4. +ve spring test
    • MRI is the gold standard diagnostic tool for groin pain in sport.
    • Poor correlation between symptoms and changes on X-ray, MRI or bone scan.
  5. MRI pubic bone marrow oedema, or changes on isotope bone scan
58
Q

What are 6 positive interview findings for pubic symphysis pain?

A
  1. Pain localised over pubic symphysis and radiating outward
  2. Pain is usually insidious and may be felt unilaterally/bilaterally.
  3. Vague pain associated with “tightness/stiffness” of the adductors during or after activity is an early warning sign
  4. Adductor pain or lower abdominal pain that then localizes to the pubic area (often unilaterally)
  5. Mechanical pain aggravated by activities (e.g. running, single leg pivoting, kicking, pushing off to change direction, sidelye, walking, climbing stairs, coughing, sneezing)
  6. Sensation of clicking or popping upon rising from a seated position, turning over in bed, or walking on uneven ground.
59
Q

What are 7 positive examination findings for pubic symphysis pain?

A
  1. Tenderness in midline pubic symphysis •+ve adductor squeeze test
  2. Spring test is only for mild symptoms.
  3. +ve spring test: Pressure through pubic rami lateral to pubic symphysis
  4. Tenderness over ≥1 para-symphysial tendons unilaterally/bilaterally (e.g. rectus abdominis, adductor longus)
  5. Pain on resisted sit-up &resisted hip flexion - abdominal pain.
  6. Pain on single leg hop - dynamic & WB ability.
  7. Restricted ipsilateral hip internal rotation - contributes to shear force at pubis.
60
Q

How do do the spring test?

A

• Go side of pelvis and palpate • Only for very mild symptoms Eg. 30 mins into exercise..etc

61
Q

What is the purpose of the single leg hop?

A

For management

62
Q

What are 7 characteristic of pubic symphysis pain in sport?

A
  1. Challenging to manage
  2. High recurrence rate
  3. Risk factors: Previous injury, low sport specific fitness in off-season, adductor weakness.
  4. MRI diagnostic tool of choice
  5. Premature return to sport – impairments in performance
  6. Persistent symptoms can lead to >1 structures involved in the presentation (~33%).
63
Q

What are 3 diagnostic tests for pubic symphysis pain?

A
  1. tenderness in the midline directly over the symphysis pubis*
  2. a positive adductor ‘squeeze’ test*
  3. positive ‘spring test’ – pressure through pubic rami – lateral to pubic symphysis*
64
Q

What are 3 associated features of the clinical scenario of central groin pain?

A
  1. tender symphysis
  2. positive adductor squeeze test
  3. either pubic bone marrow oedema on MRI or changes on isotope bone scan.
65
Q
A

PHTY2220 (31 decks)

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