Pelvic Girdle Pain Flashcards
Important features of the SIJ
synovial joint - some movement able
sacral surface has hyaline cartilage
iliac surface has increased collagen density - restricts movement
allignment of ridges/troughs on either surface - decreased ability to glide
highest friction coefficient of any joint
Interosseous Sacroiliac Ligament
from sacrum to iliac tuberosity
spans entire area
binds ilium to sacrum
most important and strongest
Posterior Sacroiliac Ligament
behind the ISL
binds the sacrum to the PSIS and iliac crest
Long Dorsal Sacroiliac Ligament
behind the ISL
limits counternutation of the pelvis
easily sensitised in SIJ
Sacrotuberous Ligament
from lower sacrum to ischial tuberosity
limits nutation
Sacrospinous Ligament
from lower lateral sacrum to ischial spine
limits nutation
Movement of SIJ - Sacrum Perspective
Nutation - forwards nodding of the sacrum
- close packed position
- pushed into nutation when standing
Counternutation - backwards nodding of the sacrum between the two innominate bones
- loose packed position
Movement of SIJ - Ilium Perspective
Antagonistic Innominate Rotation - as one innominate bone moves anteriorly the other moves posteriorly SLS - loaded leg posteriorly rotates Posterior rotation - close packed Anterior rotation - loose packed
Function of the SIJ
acts as buffer for load being transferred between teh spine and LL
stress reliever - requires some movement but overall very stable joint
Form Closure
bony structures
Sacrum shaped to wedge into joint vertically and anterio-posteriorly - icnreases stability of the joint
high collagen content iliac surface - increased stability
thick cartilage
interlocking ridges
ligamentous contribution
Overall stability
Maximal form closure during nutation/posterior rotation
Force Closure
Ligamentous Tension - generates compressive forces around the joint
- vertical wedging
- posterior rotation/nutation
- muscle insertions into ligaments
Muscle Activation - generates compressive forces around the joint
- lumbar multifidus and deep abdominal muscles
- pelvic floor muscles
- oblique sling muscles
Oblique Sling Muscles
Posterior oblique sling - latissimus dorsi and gluteus maximus
Anterior oblique sling - obliques and adductors
Longitudinal sling - biceps femoris and lumbar multifidus
Primary Dysfunction SIJ Pain
Control problem - failure of self bracing
the combination of force and form closure to allow for optimal load transference
Maladaptive load transference = failed self bracing = pain
Loose Control - insufficient force closure, underative muscles
Tight control - excessive force closure, overactive muscles
Contributing Factors
hormones sensitisation from neurobiological and hormonal factors lumbar and hip flexibility lumopelvic and hip muscle function loading history lifestyle factors psychosocial function
TIGHT CONTROL
excessive muscle activity = excessive self bracing less common fearful and anxious instability beliefs belt - helps at first then gets wrose worse with ASLR weight tranference test not clear diffuse tenderness excessive muscle activity breath holding better when they relax worse with stability exercises poor dissociation fail control tests
LOOSE CONTROL Features
insufficient muscle activity = insufficient self bracing more common SIJ belt hlps ASLR better positive weight transference test LDSIL tender on palpation decreased muscle activity better when activate muscle poor dissociation fail control tests remote factors drive anterior rotation strain
LOOSE CONTROL Psychological Management
Same as with lumbar spine
Emphasise uniqueness of SIJ structure - how stable it is
Sensitivity likely due to problem with weight loading
LOOSE CONTROL - General Function
advice on load management discourage excessive sedentary behaviour prescribe general exercise program technique modification and manual handling sleep hygeine lifestyle counseling if indicated manage comorbidities consider referral other HCP
LOOSE CONTROL - tissue sensitivity
settle pain - if in pain at time explanation and reassurance bracing SIJ belt neuromuscular massage joint mobilisation
LOOSE CONTROL - local function
Move to optimise form and force closure
- posterior innominate rotation
- sacral nutation
- HEP to achieve this
Improve muscle performance to optimise force closure
FIND IT
- independent movement into impaired directions
- train correct pelvic floor activation
CONTROL IT
- maintain neutral under provocative load
- target hip muscles to promote force closure
LOAD IT
- load under provocative direction
LOOSE CONTROL - remote function
Muscle performance to optimise force closure
- exercise to improve muscle capacity that provides force closure and/or minimises anterior rotation strain
- target glute max, hip adductors, glute med
Correct impairments that drive anterior innominate rotation or counter nutation strain
- promote hip extension
- increase extensibility/reduce activation of muscles
- promote lumbosacral extension
- consider mobilisation of opposite SIJ
