nutation
base of sacrum moves in towards pelvis
- inferoposterior glade of sacrum on ilium
- limitted by ligametns
bilateral - end range trunk flex and early extension
unilateral - hip flex
counter nutation
bckwd motion of base of sacrum moves out of pelvis
- antersuperior glide of sacrum on ilium
- limitted by post ligametns and multifidus
bilateral - end range trunk ext and early trunk flex
unilateral - hip ex6
form closure
stable situation due to closely fitting joint surfaces, no extra forces needed to maintain stability
provided by: joint surfaces: type of cartilage , ridges and grooves A/P wedging of sacrum friction co-efficient integrity of ligaments
only 4˚ ROM in sacrum
FORCE CLOSURE
extra forces needed to keep joint in place’
provided by muscles - however no muscle attaches and tendons close to joitn line
- lat dorsi, glut max, erector spinae, biceps fem
and fascia
Most SIJ pain is
MECHANICAL OR INFLAMMATORY
& INTRA-ARTICULAR OR EXTRA-ARTICULAR
SIJ symptoms to think of
Consider joint stiffness, morning stiffness and pain, swelling, multiple joints affected, other conditions present (Irritable Bowel, eye problems, skin changes, fever, fatigue)
FACTORS SUGGESTIVE OF A LOSS OF FORCE CLOSURE OF SIJ
- habitual passive postures (slump sit, sway standing, trendelenburg)
- excessive lateral pelvic and lower trunk rotation with limb loading
- poor loading strategies in weight bearing
- abdominal bracing strategies
- poor gluteal function
- inability to ‘lift’ pelvic floor and initiate a low abdominal wall contraction with controlled respiration (non-weight bearing and weight bearing)
- compromised urinary continence
- +ve active straight leg raise test
- SIJ SYMPTOMS
Unilateral pain below L5 Stiffness and pain with walking Pain opposite side with walking Pain same side with walking Pain with sit to stand or other loading activities Coccydynia pain on the buttock
need to rule out Lumbar - sx below l5, no pain with AROM or PAIVMS
piriformis syndrome
Signs and symptoms:
- Ruling out other more likely causes (referral from Lumbar Spine)
- Palpable tenderness of the Piriformis muscle with or without production of distal symptoms
- Pain reproduced with piriformis length test
- Positive Pace sign (pain reproduced with resisted external rotation and abduction of the affected hip)
pubic symph
It most often describes a clinical scenario of central groin pain with associated features of:
- tender symphysis
- positive adductor squeeze test
- either pubic bone marrow oedema on MRI or changes on isotope bone scan.
SYMPTOM HISTORY – INFO FROM INTERVIEW
pubic symph
SYMPTOM HISTORY – INFO FROM INTERVIEW
•Pain localized over the symphysis and radiating outward
•Pain is usually insidious and may be felt unilaterally or bilaterally.
•Vague pain associated with “tightness/stiffness” of the adductors during or after activity is an early warning sign
•Adductor pain or lower abdominal pain that then localizes to the pubic area (often unilaterally)
•Pain exacerbated by activities such as running, pivoting on 1 leg, kicking, or pushing off to change direction, as well as by lying on the side
•Pain occurring with walking, climbing stairs, coughing, or sneezing
•A sensation of clicking or popping upon rising from a seated position, turning over in bed, or walking on uneven ground
education
patients must be
- reassured about condition and taught self management
- encouraged to be physically active
- encourage to continue normal daily activites
- encourage to return to work asap
acute management startergies
education , MANAGE ,ATERAL SHIFT, GRADED RETURN TO ACTIVTIES, WORK ETC reassurance, exercises, motor control retraining, postural retraing
SIJ PHYSICAL EXAM
A)Standing observation B)Gait assessment C)Lumbar ROM (to rule out Lumbar) D)Provocation Tests 1.Thigh Thrust 2.Distraction 3.Compression 4.Sacral PA 5.Gaenslens Test E)Movement examination - NOT determining if SIJ is source of symptoms BUT OBSERVE WEIGHT TRANSFER Gillets test HIP EXTENSION: Assesses Ipsilateral Anterior innominate rotation & transverse rotation STORK TEST: Assesses load transference & lateral rotation
F)Palpation
G)Test for Active Stability – Active SLR
H)Muscle tests
PUBIC SYMPHYSIS PAIN (& GROIN PAIN) PHYSICAL EXAMINATION
- Observation
- Functional tests – hopping, squat, single leg squat, running (observe lumbo-pelvic control)
- Clear the Lumbar Spine AND Hip
- Palpation – include spring test if necessary
- Resisted Adduction (adductor squeeze)
- Hip ROM*
- Assessment of strength of key muscles (glute med & abdominals) (lumbo-pelvic control)
- Assessment of length of key muscles (piriformis, hamstring, thomas test)
- Consider Active Straight Leg Raise test (as for SIJ) *Hip joint restriction often precedes the development of groin pain and may be a risk factor for this condition.
