SIJ Ax and Rx Flashcards
1
Q
The true prevalance of SIJ dysfunction is:
A
extremely hard to establish, not only due to the complex anatomy of the SIJ with its many ligaments and myofascial structures which can be a source of pain, but also due to the multifactorial nature of low back pain and buttock pain
2
Q
Red Flags
A
- Age of onset <20 or >55 years
- Violent trauma, e.g. fall from height, RTA
- Constant, progressive, non-mechanical pain
- Thoracic pain
- PMH – Carcinoma
- Systemic steroids
- Drug abuse, HIV
- Systemically unwell
- Unexplained weight loss
- Persisting severe restriction to lumbar flexion
- Widespread neurology
- Structural deformity
- TB
If there are suspicious clinical features, and if pain has not settled in 6/52’s further investigations should be considered.
3
Q
Cauda Equina symptoms
A
Definite red flags:
- Bilateral radiculopathy (loss/diminished strength, feeling of touch or reflexes)
- Progressive neurological deficits in the legs
- Widespread (>one nerve root) or progressive weakness in the legs and/or gait disturbance.
Possible red/white flags:
- Unspecified urinary disturbance (any new change in bladder function but with preserved control)
- Loss of anal sphincter tone/faecal incontinence
- Saddle anaesthesia about the anus, perineum or genitals
- Erectile dysfunction or changes in sexual function
Definite white flags:
- Urinary retention or incontinence
- Faecal incontinence
- Perineal anaesthesia
4
Q
Infection symptoms
A
- General feeling unwell
- High temperature (fever)
- IVDU (intravenous drug use)
- Recent surgery / open wounds
5
Q
Cancer signs
A
- Previous Hx of cancer in themselves or family
- Unexplained weight loss
- Non- mechanical, constant pain
- Night sweats
- Generally feeling unwell
6
Q
Fracture signs
A
- Major trauma (motor vehicle accident, fall from height)
- Minor trauma or strenuous lifting in an older or osteoporotic patient
- Constant pain, worse on weight bearing
- Swelling/ bruising
- Steroid use
- Osteoporosis/ osteopenia
7
Q
Inflammatory Disorders (Ankylosing spondylitis etc.) signs
A
- Gradual onset
- Marked morning stiffness
- Persisting limitation of spinal movements in all directions
- Peripheral joint involvement/tendionpathies/aches
- Iritis, skin irritation (psoriasis), colitis, urethral discharge
- Family history
8
Q
Observation
A
- Gait:
- Excessive weight bearing through one leg
- Antalgic gait,
- Positive Trendelenberg,
- Posture during gait
- Postural alignment noting any asymmetry – scoliosis/kyphosis/flattened thoracic region
- CoG
- Adaptive postures- Pain avoidance, guarding/bracing
- Muscle tone/bulk
9
Q
AROM and PPIVM
A
Movements:
- Forward flexion (facet joints opening)
- Lateral Flexion (+ contralateral pelvic rotation)
- Extension (facet joints closing)
- Rotation in sitting (limited due to facet joint orientation)
- Quadrant testing- lateral flexion with forward flexion or extension
- PPIVMS: SIJ pain will lead to Lx stiffness. Passive physiological movements-flexion, extension and rotation
What are we looking for?
- Quality, range (record distance from floor to fingernails), end feel, =/- overpressure
10
Q
Neurological testing
A
If pain referred below the crease of the buttocks then neurological testing is indicated
-
Myotomes (look for weakness not pain)
- L2: Hip flexion
- L3: Knee extension
- L4: Dorsiflexion
- L5: Great toe extension
- S1: Eversion, contract buttock, knee flexion
- S2: Knee flexion, toe standing
-
Reflexes
- Knee Jerk (L3-4, Femoral Nerve)
- Ankle Jerk (S1-2, Tibial Nerve)
- Dermatomes
Neurodynamics:
- Slump test: sciatic nerve and above
- Patient in sitting-ask patient to slump chin to chest and sump thoracic spine forward. Physio will apply a gentle force through the patients thoracic spine and neck. Patient is asked to extend their knee to point of discomfort is posterior leg. Release pressure on thoracic spine and ask patient to extend neck. Relief from discomfort in posterior of leg indicates a positive sign of neural tension on sciatic nerve.
- Straight leg raise: sciatic nerve and branches
- With the patient lying down on his or her back on an examination table or exam floor, the examiner lifts the patient’s leg while the knee is straight and slightly medially rotated. Lift until discomfort in posterior leg- sensitise by ankle dorsiflexion or cervical flexion.
- SID - sural nerve INV + DF
- PIP - peroneal nerve INV + PF
- TED - tibial nerve EVE + DF
- PKB - femoral nerve
11
Q
Mobility tests
A
SIJ Alignment/tenderness
Low reliability and validity
-
Piedallu/seated flexion test
- Patient in sitting. The physio compares the levels of the PSIS’s. The patient is asked to flex forward. The relative position of the PSIS’s are compared through movement.
- Positive sign: the side that moves furthest or first is the kinetic positive side.
-
Standing flexion test
- As above with the patient in standing.
-
Gillet’s/Stork Test:
- Patient is in standing. The physio compares levels of PSIS and S2 on one side. The patient is asked to lift their knee to their chest. The relative position of the PSIS compared to the other side is monitored during the lifting of the leg. Repeat by lifting the other leg and then repeat on the other side.
- Positive sign: Compare movement on both sides- PSIS should move downwards relative to S2 on ipsilateral knee to chest- lack of movement or excess movement on one side indicates a positive.
12
Q
Special tests
A
Pain provocation tests for SIJ: Pain in SIJ on 3 out of 5 tests would lead you to suspect SIJ dysfunction with 79% specificity as shown by Laslett et al. (2005).
-
Laslett’s Cluster:
- Supine: Gaenslen torque test, thigh thrust, distraction
- Side lying: Compression
- Prone: Sacral thrust
-
Gaenslen torque test:
- Patient in supine. Flex hip and extend opposite hip to produce shearing forces to SIJ (similiar to getting out of bed)
-
Thigh Thrust
- Patient in supine. Flex patients hip and knee to 90 degree. Physio applies a thrusting force down through the knee and into the SIJ.
-
Anterior Gapping/distraction
- Patient in supine, physiotherapist crosses arms and places hands on patients ASIS and applies a firm pressure to “spread” the ASIS’
-
Compression
- Patient in side-lying. Physiotherapist places hands on patients hips at pocket level (iliac crest) and applies firm pressure.
-
Sacral Thrust (PA)
- The patient is prone and the examiner applies an anterior pressure through the sacrum.
13
Q
ASLR test
A
- Altered motor control in patients with posterior pelvic pain
- Has been validated to measure severity of posterior pelvic pain
- Scoring system of 0-5 for each leg
- Two parts to the ASLR are:
- Active - does it reproduce symptoms?
- Compression - do symptoms improve? If symptoms improve with compression this guides us to advise compression belt as a treatment; if compression worsens then advise against.
14
Q
What muscles cause SIJ pain:
A
Research has shown muscles of the posterior oblique sling are the ones lacking, which are:
Latissimus Dorsi, Hamstrings, Glutes and Erector Spinae muscles all of which act on the thoracolumbar fascia.
15
Q
SIJ dysfunction more likely:
A
- if pain is: very localised - poorly localised increases likelihood of Lx pain. In the ‘Fortin’ area but NOT in the ‘Tuber’ area, however pubic symphysis pain with pregnancy and lower back/ hip pain can also refer into that area too
- SIJ can occur with H/O direct trauma
- in H/O pregnancy + subsequent trauma as ligaments relax due to release of Relaxin, to allow for birth. Sometimes one side expands more than normal. May include pubic symphysis pain.
- Prognosis reduces in: greater H/O pregnancies
