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OCS prep > Pelvis and SIJ (APTA) > Flashcards

Pelvis and SIJ (APTA) Flashcards

1
Q

In general, what are the functions of the pelvis as it relates to movement?

A
  • load transfer
  • force generation
  • primary stabilization
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2
Q

Is positional palpation for the SIJ/pelvis reliable in the clinic? What about movement testing?

A
  • No positional palpation is not considered all that reliable. Pelvic bones are inherently asymmetrical
  • Movement testing is also not really all that reliable.
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3
Q

What are the 6 anatomical components of the “functional pelvic girdle?

A
  • L4-5 vertebrae
  • sacrum
  • 2 ilia
  • pubic bones
  • sacrococcygeal joint
  • hip joints
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4
Q

What is the anatomical component that more closely connects L5 to the pelvis?

A
  • iliolumbar ligament; connects L5 to the ilia more directly
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5
Q

T or F;

The sacrum is symmetrical.

A
  • F; not symmetrical and rarely shows a defined inferior angle.
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6
Q

What is a primary consideration for palpation of the PSIS?

A
  • whether you’re palpating the inferior margin (the dimple) or the promontory aspect of the PSIS.
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7
Q

T or F;

There is a hyaline cartilage layer between the pubic bones.

A
  • T; two layers separated by a fibrocartilaginous disk

- contrasted with the sacrococcygeal joint where there is just a fibrocartilaginous disk

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8
Q

What is the relationship between the rotational force of the pelvis and foot position in gait?

A
  • the pelvis generates rotational force that helps to supinate the foot between mid- and terminal stance
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9
Q

What is the general prevalence of SIJ dysfunction?

A
  • Thought to be ~13% in pts complaining of LBP, and 20% of college students.
  • Asymptomatic individuals showed positive dysfunction in screens with ~8-16%
  • For those with lumbar disk herniation, 72% also had SIJ dysfunction
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10
Q

What is the implication of the relationship between lumbar disk herniation and SIJ dysfunction?

A
  • pts w/ lumbar disk herniation should have treatment that incorporates SIJ dysfunction considerations
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11
Q

One study showed what percentage of people with leg pain had an etiology of SIJ dysfunction?

A
  • 41%

- kind of a large result; but still implies that SIJ dysfunction can present similarly to sciatica

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12
Q

T or F;

The shape of the sacrum remains the same throughout life.

A
  • F…it changes
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13
Q

When can we start to see degenerative changes occur in the SIJ?

A
  • in men, in the 4th decade

- in women, in the 5th decade

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14
Q

What type of joint is the SIJ?

A
  • a combination of diarthrosis and syndesmosis
  • The diarthrosis is the boomerang shaped joint surface
  • the syndesmosis (synarthrosis) is the posterior interosseous ligament
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15
Q

Does the SIJ have a joint capsule?

A
  • yes; comprised of the lumbosacral band of the iliolumbar ligament, superiorly;
  • then the anterior sacroiliac ligament, anteriorly
  • sacrospinous ligament, inferiorly
  • posterior interosseous ligament and posterior sacroiliac ligaments, posteriorly
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16
Q

T or F;

In WB, the sacral and iliac surfaces congruently oppose each other to provide stability.

A
  • F, but debateable
  • current evidence is generally observational at best, but there is some evidence that there is space that remains between the joint surfaces under load
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17
Q

What are the two opposing conceptual models for SIJ stability?

A
  • a “self-locking” mechanism derived from the shape and assumed congruency/friction derived in WB between the SIJ surfaces
  • a biotensegrity model, where stability is derived from the tension between interstitial layers of tissue; implies that joint spaces would not necessary approximate to create stability
  • no clear evidence either way
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18
Q

What structures are likely most responsible for load transfer in the self-bracing mechanism within the pelvis?

A
  • strong evidence that musculature is responsible, as opposed to osseous or ligamentous structures
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19
Q

What are the typical ranges of movement, in degrees and measureable distance, associated with the SIJ during functional movement? (e.g., sit<>stand)

A
  • ~1.15-2.5*

- 0.4-0.9mm

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20
Q

Which two ligaments are thought to play a large role in the stability of the SIJ?

A
  • Sacrotuberous and sacrospinous
  • Sacrotuberous connects the PSIS and sacrum to the ischial tuberosity
  • Sacrospinous connects the lower sacral/coccygeal vertebrae to the inferior aspect of the SIJ joint capsule
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21
Q

What motion(s) does the sacrotuberous ligament restrict?

A
  • flexion of the sacrum and posterior rotation of the innominate
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22
Q

What is the effect of slouched sitting on the stability of the SIJ?

A
  • disengages the sacrotuberous ligament, eliminating that structure’s influence on SIJ stability
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23
Q

What 3 muscle groups could be considered to provide stability to the spine relative to the pelvis? What is their relative orientation?

A

(sagittal plane view)

  • Deep erector spinae; posteriorly oriented
  • quadratus lumborum; inferiorly oriented along roughly midline, otherwise more strongly laterally in the frontal plane
  • psoas; anteriorly oriented
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24
Q

What are the two ways that fascia can be put on tension, conceptually?

A
  • when a muscle contracts, pulling on the fascia

- when a muscle expands against the it’s fascial compartment

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25
Q

What fascial structure can be considered of relative primary importance to pelvic functioning as a stabilizer or load transducer? Why?

A
  • thoracolumbar fascia

- so many larger muscle groups attach to this fascial network; glute max, lats, quad lumborum, erector spinae

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26
Q

T or F;

LBP is often associated with hip extension movements becoming glute max dominant with inhibition of the hamstrings.

A
  • F; opposite
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27
Q

With innominate inflare, the ASIS moves ___ and the PSIS moves ______. What hip movement is associated with this?

A
  • ASIS moves medially, PSIS moves laterally

- happens w/ hip internal rotation; opposite for outflare

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28
Q

Describe the relative sacral movements in the sagittal plane in mid-ranges of spinal flexion and extension. Same for end ranges.

A
  • in mid-range; spinal flexion creates sacral extension, and spinal extension creates sacral flexion.
  • at end ranges, spinal flexion creates sacral flexion, and spinal extension creates sacral extension
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29
Q

What happens to the ilia and pubic bones during sacral flexion? Extension?

A
  • in sacral flexion, the ilia rotate medially, and the pubic bones rotate laterally
  • in sacral extension, the ilia rotate laterally, and the pubic bones rotate medially
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30
Q

What is the difference in semantics between hypermobility and instability?

A
  • instability implies the need for surgical management

- hypermobility can be considered as impaired stability that may or may not be pathological

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31
Q

Describe the ASLR test relative to SIJ hypermobility and it’s relative relevance.

A
  • the active straight leg raise test (ASLR) compares strength symmetry. If one side is found to be weaker, the therapist applies pelvic compression, while the pt repeats the ASLR on the weak side. If the compression improves performance, the pt is thought to have pelvic hypermobility.
  • prone to miss mild-moderate hypermobility in patients that are stronger; would need to do the test with weight to improve it’s sensitivity
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32
Q

Relative to the functional pelvic girdle, what is the greatest consequence of low back pain?

A
  • impaired motor control. Significant changes happen in muscle activation, gait, and even breathing patterns.
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33
Q

What are the primary causes of hypermobility/impaired laxity?

A
  • impaired motor control/muscle activation
  • prolonged asymmetrical loading
  • pregnancy
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34
Q

What can be some causes of atraumatic ligamentous laxity for the pelvis?

A
  • prolonged asymmetrical loading

- pregnancy

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35
Q

What cluster can be used to diagnose a hypermobile pubic joint? (6)

A
  • excess movement in 3 weight bearing radiographs (>3mm in women, and 1.5 mm in men)
  • positive ASLR
  • TTP of the superior pubic ligament
  • TTP of the psoas
  • TTP of the iliacus
  • TTP of the adductors (especially pectinius)
  • 5 of 6 are needed to dx hypermobility at the pubic bone
36
Q

Current cluster SIJ dysfunction screening looks at what 6 concepts?

A
  • provocation testing
  • palpation
  • pain location
  • strength testing
  • mobility testing
  • quadrant length screening
37
Q

T or F;

Injections are the gold standard for SIJ dysfunction dx.

A
  • F;

- really no gold standard

38
Q

T or F;

Pts with confirmed SIJ pain rarely report pain at or above the L5 level.

A
  • T

- useful indicator/screening factor; however other evidence would indicate that lumbar pain does exist with SIJ pain

39
Q

What are the two clusters for SIJ pain that have been researched?

A
  • thigh thrust, sacral thrust, compression, distraction, and Gaenslen’s; 3 of 5 have good statistics; excluding those that centralize or peripheralize symptoms improves statistics; if negative on all of them, it is unlikely that SIJ dysfunction exists
  • thigh thrust, compression, distraction, FABER, and Gaenslen’s; 3 of 5 have good statistics
40
Q

What is the most promising single provocation test when screening for SIJ dysfunction?

A
  • HABER; hip abduction, external rotation

- pt in prone. hip is then moved into abduction/ER in increments >30*

41
Q

T or F;

Pain locations with SIJ pain are highly variable, and clinicians should not use pain location for diagnosis.

A
  • T
42
Q

With people who responded to SIJ intraarticular blocks, what percentage had lower lumbar pain? Buttock pain? Pain to the knee or below?

A
  • 72% lower lumbar
  • 94% buttock
  • 40% at the knee or below
43
Q

Pain in what specific location is more likely associated with SIJ pain?

A
  • PSIS
44
Q

Pain with palpation of which ligament may be assicated with SIJ pain?

A
  • long dorsal sacroiliac ligament
  • studied with peripartum patients, but the dorsal sacroiliac ligaments are likely pain generators for SIJ pain, so a decent one to look for generalization
45
Q

What isolated MMT is most appropriate for the dx of SIJ pain?

A
  • hip abductor MMT that provokes symptoms
  • ASLR testing
  • hip adductor testing, although this was studied with posterior pelvic pain after pregnancy
46
Q

T or F;

Current mobility assessments for the SIJ are unreliable.

A
  • T

- there’s really no good test

47
Q

What is the proposed test to assess SIJ movement quality? (Gillet modification)

A
  • therapist behind patient w/ hand on posterolateral pelvic girdle. Pt lifts leg into SL march. Normal movement should be purely sagittal. Aberrant movement will likely have frontal or transverse plane component (hip hike)
48
Q

How can lumbopelvic motion be used to assess general SIJ movement quality?

A
  • normal lumbopelvic rhythm is 120* of flexion, with half coming from the hip and half from the back.
  • someone with PGP will likely have less hip motion and more back motion, someone will LBP will likely have less lumbar spine motion, and more hip motion
  • more a screening tool than something diagnostic
49
Q

What may be confused for sacral motion when doing movement testing with palpation?

A
  • multifidus will activate first, followed by any sacral movement
  • multifidus activation may be mistaken for sacral movement
50
Q

Current concepts involving pelvic dysfunction are a shift away from what paradigm, and to what different priority?

A
  • shifting away from anatomical alignment diagnosis to a movement/motor control diagnosis
  • implications for treatment are to avoid trying to “realign” the structure and treat the more local/regional motor impairments
51
Q

What conclusions can be drawn from studies on pelvic girdle pain during pregnancy and post-partum, regarding SIJ dysfunction/pain?

A
  • increased laxity in the pelvic girdle can be associated with pain, with improvements created with improved stability.
  • hx of LBP in these patients is a risk factor for pain. LBP interferes with motor control/stability.
52
Q

Describe an expected clinical presentation for a pathological SIJ shear (e.g., upslip).

A
  • should have some sort of pain in the expected regions
  • may be the result of a fall landing asymmetrically on buttocks
  • should have aberrant movement; with SL march, compensation in frontal/transverse planes
  • other factors on exam would improve confidence (strength testing, palpation, etc)
53
Q

What are two decent determinants for higher incidence of SIJ dysfunction?

A
  • lower quadrant length asymmetries

- asymmetrical loading patterns

54
Q

What type of imaging is appropriate for lower quadrant screen?

A
  • standing AP view of pelvis

- looking for a level sacral base

55
Q

What is the evidence for using a heel lift to improve PGP with leg length discrepancy?

A
  • there isn’t any. kind of makes sense though.
56
Q

What are some primary red flags to consider if concerned about cancer with a PGP referral?

A
  • age > 50
  • hx of cancer
  • no improvement after 1 month of intervention

OR/and

  • failure to find relief with bed rest
57
Q

What are red flag characteristics of cauda equina syndrome to be aware of?

A
  • saddle anesthesia
  • bowel changes
  • bladder changes
  • sexual dysfunction
  • neurological deficit of the LE
58
Q

What movement can be useful to rule out fracture of the pelvis?

A
  • hip flexion with knee extension
  • should be noted that there is a greater concern for fx with trauma more than anything else. Also chronic corticosteroid use
59
Q

Pelvic fracture is most common in what region?

A
  • pubic ramus
60
Q

What are some appropriate outcome measures for PGP? Which ones are validated?

A
  • Oswestry disability questionnaire
  • Roland-Morris Disability questionnaire
  • Focus on Therapeutic outcomes
  • Patient-specific functional scale (for higher functioning pts)
  • Fear avoidance questionnaire
  • nothing is really validated for this population. Still a lot of research needs to happen
61
Q

What is the Fortin finger test? Should it be used?

A
  • Pt points to the location of their pain. To be indicative of PGP, it should be a consistent location, and w/in 1 cm of the PSIS.
  • this monograph seems to recommend it’s use
62
Q

What exam findings can help rule out a zygapophyseal etiology?

A
  • absence of pain with coughing/sneezing AND absence of pain when standing from a flexed seated position
  • Also a negative extension-rotation test
63
Q

What clinical findings can help rule out PGP?

A
  • absence of pain in single leg stance
64
Q

What clinical finding can help rule out greater trochanteric pain syndrome ?

A
  • tolerance for >30 seconds in SLS

- includes inflammatory and/or degenerative conditions of the hip abductors and the trochanteric bursa

65
Q

What is the sign of the buttock?

A
  • familiar pain generated with SLR. Then clinician flexes knee and increases hip flexion. If pain still present, or worsening, it is indicative of hip pathology, potentially requiring referral
  • evidence limited to case reports, but has face validity
66
Q

Which two PGP special tests are likely the most valuable (specificity/sensitivity)?

A
  • Posterior thigh thrust

- distraction (gapping)

67
Q

T or F;

Manipulation coupled with stabilization is an effective treatment approach in LBP.

A
  • T
68
Q

T or F;

SIJ manipulation improves muscle function.

A
  • T
69
Q

What type of mobilization has been found to be effective with superior SIJ shear?

A
  • long axis distraction/mobilization
70
Q

What technique can be used to generally mobilize the ilium in the sagittal plane?

A
  • pt in supine. Therapist brings hips into 90* flx w/ knees bent. Pull on one knee (flexion) and push on the other (extension) with matching isometric contractions of moderate intensity. Holds for ~2 seconds, with relaxation between reps, alternating.
71
Q

What technique can be used to generally mobilize the ilium in the transverse plane?

A
  • pt supine. Therapist brings one leg into 90* hip flexion, stabilizing the contralateral ASIS. Then push medially against knee w/ pt isometrically contracting (abduction).

Next, bring pt’s leg to ~45* hip flexion and adduction, then pull towards hip extension w/ pt isometrically contracting (flx).

Alternate

72
Q

What technique can be used to generally mobilize the sacrum in the transverse plane?

A
  • pt in sidelying with symptomatic side up. Therapist facing pt, brings hip to 90* flexion, with trunk moderately rotated posteriorly, but not fully. Therapist hand position similar to lumbar manip. Direct force into rotation through shoulder posteriorly, and through sacrum anteriorly with pt resisting force.
  • Next, apply downward force through the knee to generate piriformis activation. Same position. Alternate force directions.
73
Q

What technique can be used to generally mobilize the sacrum in the sagittal plane?

A
  • pt in prone
  • for flexion, heel of hand at base of sacrum, w/ fingers directed caudally. Apply gentle force w/ pt exhalation, and hold through inhalation. Repeat a few times.
  • for extension, heel of hand at apex of sacrum, w/ fingers directed cephalically. Apply force with inhalation, following extension of sacrum, then holding there during exhalation. Repeat.
74
Q

What are the general treatment principles for SIJ dysfunction?

A
  • manipulate w/ long axis distraction or other manipulation with positive diagnostic findings
  • follow-up with comprehensive stability program if stability is indicated
75
Q

What are the characteristics of phase 1 of a PGP stabilization program?

A
  • train abdominals, pelvic floor, multifidus, erector spinae, and gluteals.
  • Focus on activation, control, and grading of contraction
  • intro to neutral spine concepts, and maintaining neutral spine position with bending forward (using hips, not back)
76
Q

What are the characteristics of phase 2 of a PGP stabilization program?

A
  • use of co-contraction of phase 1 musculature to create stability, with movement of other body parts
  • initiate modified curl up, side bridge, and bird dog (McGill)
  • when pain is trending down, can progress to phase 3
77
Q

What are the characteristics of phase 3 of a PGP stabilization program? What happens if pain begins to increase during this phase?

A
  • advance phase 2. Begin prone planks, supine planks, advanced side bridges, balance therex
  • If an increase in pain, regress to phase 2
78
Q

What are the characteristics of phase 4 of a PGP stabilization program?

A
  • focus on endurance. Increase in reps, not hold time with exercises.
79
Q

What are the characteristics of phase 4 of a PGP stabilization program?

A
  • focus on strength. Increase weight/intensity and decrease reps.
80
Q

Is a pelvic belt appropriate for a pt w/ PGP?

A
  • yes, they’re fine, and effective. Mechanism is not clear, as they do not offer significant mechanical stability. Goal would be to be able to wean from the belt.
  • typically for pts that are hypermobile
81
Q

Are injections of anesthetic or steroid appropriate for PGP management?

A
  • given current evidence, yes they are appropriate if indicated.
82
Q

Is neurotomy appropriate for PGP management?

A
  • unclear, but given current evidence, sure. Physicians aren’t likely to go there first, as intra-articular injections are cheaper and less likely to have complications.
83
Q

What is prolotherapy and when is it indicated?

A

Prolotherapy is the injection of substances that are designed to create an inflammatory response to facilitate fibroblast activity and promote collagen synthesis. Shows validity in rat studies.

Indicated with significant instability that has failed conservative care.

Evidence is mixed in terms of its efficacy.

84
Q

Is platelet rich plasma (PRP) appropriate for SIJ dysfunction?

A
  • really no research available for the SIJ, but it has been used with some good effect in the knee joint in younger patients
  • thought to accelerate the healing process and improve healing quality
85
Q

Is SIJ fusion appropriate for management?

A
  • it is not inappropriate. Still not too much known, as they don’t happen that often. CRIF is starting to show more promising outcomes than ORIF.

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