Pelvic Girdle Pain

Question 1

Important features of the SIJ

Answer 1

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

Question 2

Interosseous Sacroiliac Ligament

Answer 2

from sacrum to iliac tuberosity
spans entire area
binds ilium to sacrum
most important and strongest

Question 3

Posterior Sacroiliac Ligament

Answer 3

behind the ISL

binds the sacrum to the PSIS and iliac crest

Question 4

Long Dorsal Sacroiliac Ligament

Answer 4

behind the ISL
limits counternutation of the pelvis
easily sensitised in SIJ

Question 5

Sacrotuberous Ligament

Answer 5

from lower sacrum to ischial tuberosity

limits nutation

Question 6

Sacrospinous Ligament

Answer 6

from lower lateral sacrum to ischial spine

limits nutation

Question 7

Movement of SIJ - Sacrum Perspective

Answer 7

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

Question 8

Movement of SIJ - Ilium Perspective

Answer 8

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

Question 9

Function of the SIJ

Answer 9

acts as buffer for load being transferred between teh spine and LL
stress reliever - requires some movement but overall very stable joint

Question 10

Form Closure

Answer 10

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

Question 11

Force Closure

Answer 11

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

Question 12

Oblique Sling Muscles

Answer 12

Posterior oblique sling - latissimus dorsi and gluteus maximus
Anterior oblique sling - obliques and adductors
Longitudinal sling - biceps femoris and lumbar multifidus

Question 13

Primary Dysfunction SIJ Pain

Answer 13

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

Question 14

Contributing Factors

Answer 14

hormones 
sensitisation from neurobiological and hormonal factors 
lumbar and hip flexibility 
lumopelvic and hip muscle function 
loading history 
lifestyle factors 
psychosocial function

Question 15

TIGHT CONTROL

Answer 15

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

Question 16

LOOSE CONTROL Features

Answer 16

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

Question 17

LOOSE CONTROL Psychological Management

Answer 17

Same as with lumbar spine
Emphasise uniqueness of SIJ structure - how stable it is
Sensitivity likely due to problem with weight loading

Question 18

LOOSE CONTROL - General Function

Answer 18

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

Question 19

LOOSE CONTROL - tissue sensitivity

Answer 19

settle pain - if in pain at time 
explanation and reassurance 
bracing SIJ belt 
neuromuscular massage 
joint mobilisation

Question 20

LOOSE CONTROL - local function

Answer 20

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

Question 21

LOOSE CONTROL - remote function

Answer 21

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