Pelvic Girdle Flashcards
What are big ligaments in the pelvis (anterior and posterior views)?
Iliolumbar, anterior sacroiliac, sacrospinous, and sacrotuberous ligaments
Posterior view: iliolumbar, posterior sacroiliac, dorsal sacroiliac, sacrotuberous, sacrospinous
What muscles are in layer one of the pelvic floor musculature?
Bulbospongiosus, ischiocavernosus, superficial transverse perineal
What muscles are in layer 2 of pelvic floor musculature?
Sphincter urethrae, compressor urethrae, deep transverse perineal
What muscles are in layer 3 of pelvic musculature?
Iliococcygeus, puborectalis, pubococcygeus (elevator ani)
What are last two muscles of pelvic floor muscles?
Coccygeus and obturator internus
What is posterior musculature of the pelvis?
Gluteus max, med, min Pisiformis Obturator internus and externus Quadratus femoris Adductor magnus, long us Hamstrings Gemelli
What is anterior musculature of the pelvis?
Psoas Iliacus RA External/internal obliques TA Adductor longus/brevis Gracilis TFL
What are the “core” muscles?
Pelvic floor
TA
Multifidus
Diaphragm
What is importance of the “core” muscles?
Control intra-abdominal pressure
Important for proper body mechanics, breathing, and voiding
What is function of pelvic floor muscles?
Supportive: helps support organs and forms bottom of the core
Sphincteric: controls openings of urethra, rectum, and vagina
Sexual: orgasms, arousal, and relaxation
Stability: assist in stability of SI, pubic symphysis, lumbosacral, and hip joints
Sump-pump: venous, lymphatic pump
What are joint characteristics of the SI joint?
Synovial, hyaline cartilage on sacral side, fibrous cartilage on ilial side, fibrous/synovial joint capsule, L shaped
What are bones of the pelvic girdle?
Bony pelvis, sacrum, spine, two femur bones
What are the sacral biomechanics?
It is self locking Greater the WBing tighter it's held Moves in sagittal plane mostly, but can move in all 3 planes Moves as effect of hip and lumbar mvmt Somewhere between 2-12 degrees
What happens in nutation?
Transverse axis Base moves inferiorly and anteriorly Apex and coccyx moves superiorly and posteriorly Ilia rotate in Ischial tuberosities separate Lumbar spine extends
What happens in counternutation?
transverse axis
Base moves superiorly and posteriorly
Apex and coccyx move inferiorly and anteriorly
Lumbar spine flexes
What is innominate movement?
Ant-post direction together or opposite
Frontal plane motion around sacrum
Bicondylar joints; one can move anterior while other goes posterior (still meets rule of bicondylar joints)
What is anatomy and biomechanics of pubic symphysis joint?
Not synovial
Cartilagenous
Moves very little: 1-2 mm
What is biomechanics of pelvis during gait?
Swing phase (L): sacrum rotates R and lumbar spine rotates opposite Heel strike (L): L piriformis contracts, sacrum rot L Pubis moves cephally at heel strike on same side
What contributes to stability of SI joint?
Force and Form Closure
How is force closure achieved?
neuromuscular control
TrA, Multifidus, pelvic floor, and diaphragm
Anticipates movement
What is a good way to test force closure?
single leg stance, ASLR
How is form closure achieved?
ligamentous support, wedge shape/design of joint and weight bearing forces
What are dysfunctions of pelvic floor musculature?
Weakness
Hypertonus
What does weakness of pelvic floor muscles lead too?
incontinence, LBP, joint instability, prolapse, pelvic congestion, muscle imbalance
What does hypertonus of pelvic floor muscles lead to?
pelvic and low back pain, sacroiliac and hip imbalances, incontinence, voiding dysfunctions, constipation, pelvic congestion
What is clinical presentation of core muscle weakness?
Leaking urine (with sneeze, cough, activity, strong urge)
Voiding dysfunction (weak stream, hesitant stream, stops midstream, not empty completely, going too frequently)
Heavy feeling in perineum or abdomen
Pelvic, LB, SIJ, Hip pain
Poor posture
Poor force closure of SIJ, poor stability of lumbosacral region
Someone walks into your clinic and reports leaking urine, problems with going to the restroom, and heavy feeling in abdomen. You also notice they have poor posture. What might be their diagnosis?
Core muscle weakness
What are risk factors for core muscle weakness?
Pregnancy and child birth Persistent heaving lifting Being overweight Changes in hormone levels at menopause Lack of general fitness Chronic or prolonged coughing Pelvic or abdominal surgery Constant stress i.e. young athletes Muscle imbalances
What is clinical presentation for hypertonus dysfunction?
Pain in back, perivaginal, rectal, lower abdomen, coccyx, or posterior thigh
Vulvar or clitoral burning
Testicular, scrotal, penile pain or burning/tingling
Pain with intercourse, defecation, sitting, tampons
Incontinence or voiding dysfunction
Constipation
Poor posture, poor stability of lumbo-sacral region
Overuse of large, global musculature weakness of core system
Hip joint decreased ROM and/or joint play
Someone comes into your clinic and c/o constipation, incontinence, pain in coccyx and rectal area, and scrotal pain. You find they have poor posture and decreased hip ROM. What is possible diagnosis?
Hypertonus of pelvic floor muscles
What are risk factors for hypertonus?
Direct fall on butt, coccyx, or pubic bone
PFM tightening (stress, habit, crossing legs)
Abdominal and pelvic adhesions
Episiotomy or tearing with childbirth
Pelvic, abdominal, hip, or back surgery
Connective tissue disease (fibromyalgia)
History of sexual abuse
STDs, or recurrent perineal infections (yeast)
Muscle imbalances
Pregnancy/childbirth
Treatment for cancer
Where is pelvic girdle pain located and possible factors for it?
Pain in one or more of joints of pelvic girdle: symphysis pubis, lumbosacral joints, sacroiliac joints, hip joints
Possible factors include hormones, biomechanics, trauma, inadequate motor control and stress of ligamentous structures
Do women get pelvic girdle pain?
20% of pregnant women and 5-8% of women post partum experience pelvic girdle pain
Women with PGP show 32-68% more motion in pelvic joints than healthy controls
What is clinical presentation of pelvic girdle pain?
Sudden or insidious onset
Typically 24-36 weeks gestation, post partum
Pain posteriorly at SIJ/gluteal area, symphysis pubis, groin, perineum, posterior thigh
Lack specific nerve root distribution, but often have positive neural tension tests
Difficulty getting up from sitting, rolling in bed, sitting for prolonged periods, prolonged walking, dressing and carrying, climbing stairs, single leg stance
A women comes to your clinic and reports sudden pain in her gluteal area, difficulty sitting/walking for a long time, and walking stairs. She is pregnant. What is a possible diagnosis?
Pelvic girdle pain
What are risk factors for pelvic girdle pain?
History of previous LBP/PGP or pelvic trauma
Multiparous
Little evidence for any others
From articles, what are signs and symptoms for someone with SIJ pain?
SIJ: butt, posterior thigh/calf, unilateral SI, lumbar pain; eased with walking; L2-S2 referred pain; ipsilateral increase in erector spinae tone, swelling over dorsal aspect of sacrum, pain changed by torsion
From articles, what are signs and symptoms for someone with iliosacral pain?
Subcostal pain, 12th rib pain, groin pain, SI pain, piercing hip pain, pain with cough/sneeze
From articles, what are signs and symptoms for someone with pubic symphysis pain?
Leg feels heavy, dull ache groin/posterior thigh or calf, burning heel pain, sit to stand on opposite side dysfunction, rolling in bed is painful, step up on unaffected side, “shuffle” in gait
Someone comes in with butt, posterior thigh/calf, unilateral SI, lumbar pain; eased with walking; L2-S2 referred pain; ipsilateral increase in erector spinae tone. What do they have?
SIJ pain
Someone comes in with Subcostal pain, 12th rib pain, groin pain, SI pain, piercing hip pain, pain with cough/sneeze. What do they have?
Iliosacral pain
Someone comes in with Leg feels heavy, dull ache groin/posterior thigh or calf, burning heel pain, and “shuffle” in gait. What do they have?
pubic symphysis pain
What is history of someone with pelvic girdle pain?
Parity and previous childbirth history Previous LBP/PGP Previous pelvic trauma/musculoskeletal trauma Aggravating movements Easing positions/pain reduction techniques Social/emotional history Nutritional Exercise General health history
What is history/important factors regarding DD (differential diagnosis)
Trauma/injury to bone or skin Recent infection Immunocompromised Radiation treatment Over/under weight Oral contraceptives HRT Inactivity Chemical exposure Female athlete triad Cancer Spine disc injury, or stenosis Recent surgery (C section) Diabetes Edema Pain, tenderness Warmth, fever Severe LBP, numbness Changes in bowel/bladder Prior D&C
What is differential diagnosis for pelvic girdle pain?
Bone or soft tissue infections UTIs Femoral vein thrombosis Obstetric complications Bone or soft tissue tumors Cauda equine syndrome Lumbar disc lesion Hip joint pathology
What changes happen in pelvic girdle during pregnancy?
Changes in rib angle to more perpendicular
diaphragm is elevated 4 cm, center of gravity is shifted, abdominal wall is distended, core function is limited, hormonal changes create an environment that is very lax
What are obstetric complications?
Incompetent cervix, HTN, gestational diabetes, multiple gestation, placenta previa/abruption, oligo/poly hydramnios, long term disabilities
During therapy what should be closely monitored?
BP, HR, RPE Contractions/hr Fluid retention Fluid loss Vaginal bleeding
What should you do if patient does have OB complications?
avoid Valsalva
avoid trunk stabilization/ab work
teach patient to self monitor
provide emotional support and education regarding C-section
What are general pregnancy concerns for therapy?
Supine position for more than a minute or two after first trimester
Gross hypermobility/laxity
Changes in center of gravity
HR below 140 bpm
What are contraindications for therapy during pregnancy?
Heat over belly
E-stim/US over belly or low back
What are good positions for labor and delivery?
Positions that minimize movement Avoid asymmetrical postures Birthing pool, exercise ball Upright and forward leaning Assisted squat 4 point positions
WHat does Cochrane review say about women who utilize upright positions during labor?
Have shorter duration of first and second stages of labor
Experience less intervention
Report less severe pain
Report increased satisfaction with childbirth experience
What are red flags for women after pregnancy? (post partum depression)
Reports she hasn't slept in 2 or 3 days Losing or gaining weight rapidly Cannot get out of bed Ignoring basic grooming Seems hopeless "Children would be better off without me" Actively abusing substances Makes strange or bizarre statements Expresses extreme anxiety or obsession regarding baby's health or safety Feels inadequate, numb, helpless Shows lack of feeling for baby or others Shows or reports inability to care for baby
What causes pelvic floor trauma?
Position during delivery Size of fetus Speed of delivery: pushing too long or short ( 2 hrs) Forceps/vacuum extraction Episiotomy or tearing or perineum
What problems may be caused from trauma to pelvic floor?
Incontinence
Prolapse
Pain: muscle or soft tissue pain, scar pain; pain due to nerve compression injuries; lumbar spine; sacroiliac, coccyx, pubic symphysis joint pain
What are the 3 types of incontinence?
Stress: leaks with increased abdominal pressure
Urge: leaks with strong urge to go
Mixed: symptoms of both
What is diastasis recti?
separation of rectus abdominis muscle along the linea alba
What are symptoms of prolapse?
“falling out feeling”
Difficulty defecating or initiating urination
Strengthening PFM can help, but if it’s true prolapse surgery or pessary are best treatment
What is MOI for SI joint?
Females Hormonal changes during pregnancy Habitual unilateral standing Childbirth strains Habitual sleep and sitting postures Hypermobility Muscle imbalance/weak stabilizers Fall on ischium Direct trauma to pubic bone Childbirth Fall onto straight leg Shear forces in sports (kicking, running) Excessive hip abd (esp with epidural) Missed step
What is osteitis pubis?
inflammatory response at pubic symphysis and ischial rami caused by sustained or repetitive trauma (athletes, surgery, prego) to pubic symphysis
What are signs and symptoms of osteitis pubis?
Localized pain and tenderness
X-ray findings: sclerosis and demineralization of cortical bone, widening of symphysis; lab behind clinical Sx by several month
What happens with pubis symphysis dislocation?
Separation of pubic bones anteriorly leads to outflaring of iliac bones, sacrum is less tightly held and can move anteriorly
Treatment: joint alignment, modalities, rest, stabilization (adductors, RA)
How does pregnancy cause pelvic pain?
Muscles, nerves, joints are injured during pregnancy, labor, and delivery (even with easiest of labors)
PFM are stretched to their max rapidly with fast deliveries or worked to max endurance with prolonged pushing
Causes of pelvic pain in the female athlete?
Disordered eating Over-exerciser Low weight Irregular menstruation or amenorrhea Leads to poor bone health Psychological condition
What is endometriosis?
Endometrial tissue grows outside uterus
Affects primarily ovaries, bowel, and bladder
Cells act as if they were part of uterine lining and continue to thicken, break down and bleed during menstrual cycle
Inflammation and scarring/adhesions result
Causes pain and can impact fertility
What are parts of assessment for pelvic girdle?
Alignment of spine and pelvis in all positions
Specific muscle strength and length tests
Palpation: diaphragm, suspect muscles
Posture and body mechanics
Diastasis recti
Functional strength tests
Standing squat: look for pelvic ring/thoracic ring movement
Active SLR
Single leg stance/squat: hip drop, hip IR, knee pronation, foot pronation, trunk flexion=gluteal weakness
SI pain provocation tests
FABER
Palpation of Dorsal Sacroiliac ligament (just below PSIS)
Neural tension: slump, SLR, femoral n, ULTTs (use these tests for exercise; 5-10 reps/day)
How do you assess DRA?
Test in hooklying
patient lifts head to engage RA
therapist places two fingers above/below umbilicus
If muscle separates to allow 2 or more fingers it is considered a diastasis
What is treatment for DRA?
Splint the muscles (kinesiotape can be helpful)
Help them find a binder to wear most of the time, especially with activity
Teach how to engage core without RA
Strengthen TA, multifidus, PFM
Coordinate diaphragm with these so they can lift/bend without increasing abdominal pressure
How do you treat coccydynia?
Body mechanics and posture Pelvic floor exercises Positioning Mobilization Soft tissue work Modalities: ice, e-stim, US, taping
How do you assess pelvic floor?
Systems review, voiding patterns, diet/fluid intake, musculoskeletal exam, external exam, internal exam, surface EMG of PFM
What is external exam for pelvic floor?
skin integrity, reflex testing, Qtip test for sensitivity, general position of perineum, observe contraction, cough, bear down, and external palpation
What is internal exam for pelvic floor?
vaginal or rectal sensation pain strength: power (0-5), endurance (1-10 sec), number of reps (1-10), and number of quicks (1-10) Normal strength is 5/10/10/10 Prolapse, cystocele, rectocele
What is surface EMG?
External electrodes or internal vaginal/rectal probe
Allows patients to receive auditory and visual feedback on a computer screen
What is surface EMG useful for?
effective way of teaching use of these muscles which can be difficult to train
Information regarding muscle relaxation and contraction patterns
Immediate feedback to patients
What are objective findings for hypertonus dysfunction?
Increased tone of PFM
Increased tone of associated mm of hip and trunk
Muscular imbalance and incoordination of hip and trunk
Mobility impairment of scar and connective tissue of perineum, inner thighs, and abs
Diaphragm tightness and poor use
Dysfunction of pelvic joints
Poor posture
Hypersensitivity of perineum
What are objective findings with weakness?
Poor posture: posterior pelvic tilt and “hangs on ligaments”
Weak and hypermobile hips/spine, or guarded due to pelvic weakness
Weak gluteal muscles
Prolapse
Weak abdominal wall
What are the normal bladder habits?
Void 5-7 times in a 24 hour period, about every 2-3 hours during the day
Should not have to get up at night to pee (over 65, it’s ok to get up once)
Never have to strain to start flow
Never go “just in case”- trains your bladder that you can’t wait
Shouldn’t ignore the urge to urinate longer than 4-5 hours
What are the mechanics of going pee?
Bladder is a smooth muscle
As it fills it stretches, the stretch is signal to brain the bladder needs to be emptied
Pelvic floor should contract and send a strong signal to bladder to relax, and the pelvic floor will manage urge until body takes it to the bathroom
When you void, your pelvic floor has to relax and the bladder contracts to empty
What are normal bowel habits?
1-3x daily or every other day
Consistency 3-4 on Bristol Stool Scale
No straining
What are mechanics of poop?
Abdominal wall is relaxed but firm
Pelvic floor relaxes and elongates
No breath holding
Use step stool to bring knees about hips
What is treatment for pelvic pain?
Pain control: positioning, body mechanics/posture, soft tissue massage (deep tissue, myofascial), muscle release (ischemic release, strain/counterstrain, positional release), exercise
Joint mobs/manips
Pelvic alignment and stability program
Patient education
What is weakness/stability protocol?
Strengthen PFM, abs, and multifidus (make sure they don’t over fire RA, start with prone gluteal work)
Teach diaphragmatic breathing as a tool for stress/pain/hypertonus management
Coordinate pelvic floor with diaphragm and core
Educate about posture
Address an muscle imbalances
Positivity journal
What is hypertonus/mobility protocol?
Relaxation or "down training" of PFM using biofeedback Contract/relax to fatigue Diaphragmatic breathing for stress/pain Trigger point release/soft tissue mobilization ANS calming Stretching exercises Postural and body mechanics education Positivity journal
What about using SI belts?
Use for short time periods
Decreases mobility of joints and provide force closure
Best position below ASIS
Should notice relief of pain and ease of lifting leg either in standing or supine
May aggravate symptoms so use individually
What is diaphragmatic breathing technique?
Inhale, expanding the abdomen without chest movement: this relaxes/elongates pelvic floor
Exhale, allowing abdomen to fall: diaphragm and pelvic floor recoil back to resting position
What are benefits of diaphragmatic breathing?
Calms sympathetic nervous system, bringing in parasympathetic nervous system Lowers HR Boosts immune system Decreases inflammation Boosts happiness
What are the things you should write in your positivity journal (positive affect)?
Gratitude
Good things that happen each day
Random acts of kindness
Savor the day
What makes it easier for women to talk about sexual concerns?
Pt has seen practitioner before
Practitioner knows pt, seems concerned about sexual wellness, has professional demeanor, is comfortable, and is kind/understanding
