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ACRONYM LIST
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AROM: active range of motion
AS: ankylosing spondylitis
ASIS: anterior superior iliac spine
ASLR: active straight leg raise
axSpA: axial spondyloarthritis
CGRP: calcitonin gene-related polypeptide
CPM: conditioned pain modulation
DRI: Disability Rating Index
EMG: electromyographic
FABER: flexion/abduction/external rotation
FABQ: Fear-Avoidance Beliefs Questionnaire
LBP: low back pain
MRI: magnetic resonance imaging
nr-axSpA: non-radiographic axial spondyloarthritis
ODI: Oswestry Disability Index
OSPRO-YF: Optimal Screening for Prediction of Referral and Outcome-Yellow Flag
PCS: Pain Catastrophizing Scale
PGP: pelvic girdle pain
PGQ: Pelvic Girdle Questionnaire
PHQ-9: Patient Health Questionnaire-9
PPT: pressure pain threshold
PRPGP: pregnancy-related pelvic girdle pain
PSIS: posterior superior iliac spine
QBPDS: Quebec Back Pain Disability Scale
QST: quantitative sensory testing
RMDQ: Roland-Morris Disability Questionnaire
SIJ: sacroiliac joint
S-LANSS: Self-administered Leeds Assessment of Neuropathic Symptoms and Signs
TENS: transcutaneous electrical nerve stimulation
TSK: Tampa Scale of Kinesiophobia
TUG: Timed Up and Go
VAS: visual analog scale
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6
The Pelvic Girdle:
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Evidence-Informed Physical
Therapy Patient Management
Kathleen Chizewski Caulfield, PT, DPT, OCS, FAAOMPT
University of Minnesota
Minneapolis, Minnesota
Leanna Blanchard, PT, DPT, CLT, OCS, FAAOMPT
University of Illinois Hospital & Health Sciences System
Chicago, Illinois
Michael O’Hearn, PT, MHS, OCS, FAAOMPT
Spectrum Health Lakeland
St. Joseph, Michigan
Carol A. Courtney, PT, PhD, ATC, FAAOMPT
Northwestern University
Chicago, Illinois
ABSTRACT
is monograph provides a pragmatic approach to physical
therapy management of pelvic girdle pain (PGP), beginning
with an overview of the updated research relevant to PGP
followed by a discussion of aberrant pain mechanisms that
may be associated with this body region. Relevant functional
anatomy and kinesiology will be reviewed, recognizing that use
of an anatomic diagnosis alone is insufficient to guide physical
therapy treatment. A detailed outline for physical therapy
examination and evaluation will be provided to guide effective
mechanism-based intervention. e history of palpation-based
and movement dysfunction-based tests will be reviewed, while
acknowledging that using these tests in clinical practice is not
strongly recommended. Accordingly, pain provocation-based
tests and clinical assessments of pain will be the focus of the
examination and evaluation section. e monograph will
culminate with 4 case scenarios to apply concepts discussed in
the monograph. e cases will focus on the ability to screen for
red flags, management of the peripartum patient, differential
diagnosis, and pain mechanisms-based management, including
decision making on when to refer to a pelvic health specialist.
Key Words: nociplastic pain, pregnancy, sacroiliac joint
LEARNING OBJECTIVES
Upon completion of this monograph, the course participant
will be able to:
1. Define the 3 classes of biological pain mechanisms (noci-
ceptive, nociplastic [non-nociceptive], and neuropathic) as
they relate to pelvic girdle pain (PGP).
2. Understand how psychosocial factors can influence the pain
experience in the context of PGP.
3. Integrate knowledge of pain into the physical therapy
evaluation and treatment of the movement system specific
to PGP.
4. Understand anatomical and biomechanical factors that
influence the evaluation and treatment of PGP.
5. Rule out common red flags that may be disguised as
mechanical PGP.
6. Conduct a thorough history/interview specific to PGP.
7. Perform a physical examination using evidence-based tests
and measures specific to PGP.
8. Identify the need for referral to a pelvic health specialist
or other appropriate health care provider such as a
genitourinary specialist.
9. Identify and describe common conditions that affect the
pelvic girdle.
10. Develop a working hypothesis and differential diagnosis
for PGP.
11. Integrate common PGP self-report with performancebased outcomes measures.
Interpret the results of a pelvic girdle examination to
12.
develop an optimal plan of care.
13. Apply evidence-based interventions for PGP.
14. Discuss management strategies for identified psychosocial
impairments as they relate to PGP.
15. Understand how treatment for pregnancy-related PGP may
differ from non-pregnancy-related PGP.
PRE-LEARNING ASSESSMENT
A 50-year-old female presents to outpatient physical
She denies any recent injury, but states that she has had similar
pain intermittently since having her last child 13 years ago. She
reports she has had 2 children, both by uncomplicated vaginal
delivery. She works as a boutique fitness studio owner, and notes
that occasionally she has to teach classes when her instructors
call in sick. She denies any bowel or bladder incontinence or
retention and denies pain with intercourse. She denies any
paresthesia, but states that the pain is in the right buttock, and
she occasionally also feels pain in the right lumbar region and
right lateral thigh. She describes the pain as deep and aching
with occasional sharpness. Aggravating factors include going
up stairs, teaching step classes at her fitness studio, prolonged
standing, and prolonged walking. Alleviating factors include
rest and gentle stretching. She denies any significant past
medical or surgical history.
Lumbar range of motion is mildly limited in all planes
but without concordant pain. Lumbar joint accessory mobility
also reveals hypomobility but without concordant pain.
Hip screening is unremarkable. e patient’s familiar pain is
reproduced by the sacral thrust, right thigh thrust, and right
sacroiliac joint (SIJ) compression tests. e SIJ gapping and
Gaenslen tests are non-painful. You suspect nonspecific SIJ pain
to be the primary problem.
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1. Upon completion of a pain diagram, a patient with
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nonspecific SIJ pain is most likely to demonstrate the highest
intensity of pain around the:
a. Greater trochanter.
b. Posterior superior iliac spine.
c. Sacral base.
d. Ischial tuberosity.
e correct answer is b. Posterior superior iliac spine.
Nonspecific SIJ pain is typically posterior in nature. Pain at
the posterior superior iliac spine (adjacent to the Fortin area)
without pain in the ischial tuberosity area has been described
as most likely to be SIJ in origin. ough patients who present
with chronic pain can demonstrate more widespread pain
distribution (including the tuberosity), intensity mapping
is helpful to better delineate likely pain generators. is is
reviewed in the history and interview section.
2.
is patient’s job demand of occasionally teaching high
intensity exercise classes is an example of a:
a. Red flag.
b. Yellow flag.
c. Black flag.
d. Blue flag.
e correct answer is d. Blue flag. Blue flags are a
component of yellow flags, and often are related to workplace
demands, time pressure, and other features that could cause an
increase in symptoms. Black flags also are a subset of yellow
flags, and are similar to blue flags, however, they relate more
to policy and work conditions that are out of the employee’s
control. Red flags are medical screening tools to determine
risk of a serious pathology as a possible cause of pain. is is
reviewed in the history and interview section.
3.
e appropriate first line of physical therapy treatment for
nonspecific SIJ pain may include:
a. Educate patient on the effect of SIJ subluxation (slips) on
pain and dysfunction.
Medical interventions, such as sclerosing injections of
b.
the SIJ.
c. Manual therapy and therapeutic exercise for pain
modulation.
d. Complete restriction of activity and wearing a pelvic belt.
e correct answer is c. Manual therapy and therapeutic
exercise for pain modulation. Manual therapy and therapeutic
exercise are recommended for treating nonspecific SIJ pain,
depending on patient presentation and needs. e therapist
must employ clinical reasoning to determine the most relevant
manual therapy techniques and most appropriate exercises.
One aspect of this clinical reasoning will be to determine
the dominant pain mechanism in the patient presentation.
Nonspecific pelvic girdle pain can include components of both
nociceptive and nociplastic pain. ese interventions are all
discussed in the section on conditions-specific evidence-based
rehabilitation concepts. Pain mechanisms in chronic pelvic
girdle pain are discussed after the anatomy and kinesiology
sections.
4.
Which ligament is most commonly tender in peripartum
females?
a. Sacrotuberous ligament.
b. Long dorsal SIJ ligament.
c. Iliolumbar ligament.
d. Short dorsal SIJ ligament.
e correct answer is b. Long dorsal SIJ ligament. Located
just inferior to the posterior superior iliac spine, the long dorsal
SIJ ligament is a potential pain generator in pregnancy-related
pelvic girdle pain. Relevant capsuloligamentous tissues and their
implications in pelvic girdle pain are reviewed in the anatomy
and kinesiology section.
INTRODUCTION
Globally, it is estimated that 1 in 5 adults suffer from
moderate to severe chronic pain.
is estimated that approximately 20% (50 million people)
2
have chronic pain
with low back pain (LBP) as one of the
leading causes. e lifetime prevalence of LBP is reported to
be in the range of 51% to 84%.
to the burden of chronic pain, LBP is the leading cause of
4
disability worldwide.
It is important to recall that LBP is a
symptom rather than a disease and the most common type
of LBP is characterized as nonspecific.
many potential sources, including the sacroiliac joint (SIJ)
and pelvic girdle. Sacroiliac joint pain is reported to affect
between 15% and 30% of individuals with chronic, non-
6
radicular LBP.
Altered central nociceptive processing may
offer one explanation for why the SIJ may be implicated in
chronic LBP. Specifically, acute joint injury of the lumbar spine
may include facet sprain or disc injury; however, chronic LBP
facilitates central nociceptive processing, accentuating the pain
experience even in the absence of noxious stimuli. Nociplastic
pain, defined as pain that arises from altered nociception despite
no clear evidence of actual or threatened tissue damage causing
the activation of peripheral nociceptors or evidence for disease
or lesion of the somatosensory system causing the pain, may
present clinically as an expansion of pain distribution beyond
the area of the original insult.
With regard to LBP, this expanded distribution of pain may
include the SIJ, making clinical diagnosis of the pathoanatomical
injury difficult. Chronic peripartum pelvic pain commonly
presents with pain at the SIJ. is condition is multifaceted and
can be difficult to differentiate from LBP or pelvic girdle pain
(PGP), due in part to the fact that pregnancy-related predictors
1
In the United States, it
3
In addition to contributing
5
Nonspecific LBP has
7,8
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for long-term peripartum pelvic pain include a previous history
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9
of LBP.
is close anatomical relationship between the lumbar
spine and pelvic girdle should be considered when examining
and treating PGP. Although rare, visceral disorders of the
gastrointestinal, genitourinary, or cardiovascular systems may
also cause LBP or PGP. Careful differentiation is required to
identify the actual source of pain in these conditions.
Low back pain is usually defined by pain between the 12th
rib and the gluteal fold. In this monograph, to differentiate PGP
from LBP we will use the definition developed by Vleeming et
al to define PGP as “pain between the posterior iliac crest and
the gluteal fold, particularly in the vicinity of the SIJ. Pain may
radiate to the posterior thigh and can also occur in conjunction
with/or separately in the symphysis.”
10
Historically, PGP has been divided into 3 broad categories:
pregnancy-related PGP (PRPGP), specific pathology such as
arthritis or fracture, and nonspecific PGP (of other origin).
10
Pelvic girdle pain is now recognized as a multifactorial problem
11
involving both biological and psychosocial mechanisms.
e
complexity of PGP has led to a wide variety of expert perspectives
as well as a variety of treatment approaches with varying levels
11
of evidence supporting their use.
While it is widely accepted
that there are both biological and psychosocial mechanisms
involved in PGP, a bias towards biomechanical factors causing
symptoms continues to prevail in clinical practice despite little
11
evidence for this approach.
Assessment of pathoanatomical
processes involved in PGP should not be disregarded; however,
the extent to which they contribute to the pain experience is
not clear. Visceral pain, particularly of the genitourinary system,
may mimic musculoskeletal conditions or contribute to their
chronicity. It is therefore important to recognize when pain is
due to a visceral source and initiate referral to an appropriate
specialist. Considering the above, a new clinical reasoning
framework is clearly needed for PGP.
12
It has been suggested that the focus of treatment for LBP
should move away from pathoanatomical causes and toward
5
reduction of pain and its consequences.
Yet, identifying
aberrant mechanisms of pain in the clinical setting has been
hampered by health care providers’ lack of knowledge on this
topic as well as limited outcome tools and assessment techniques
developed for this purpose. Pelvic girdle pain, a subset of LBP,
is complex, diverse, and multifactorial; thus, it requires more
than a biomechanical approach and management should mirror
11–13
the approach now taken with LBP.
While keeping in mind
the 3 broad categories of PGP: PRPGP, specific pathology,
and nonspecific PGP, this monograph will also suggest a more
comprehensive approach to evaluation and management.
At the center of this clinical reasoning framework will be the
patient’s pain experience and resulting self-reported disability.
Accordingly, psychosocial factors, co-morbidities, genetics, and
relevant pathoanatomy will be addressed.
When focusing on pain mechanisms for management
of chronic PGP, it is important to classify the type of pain
presentation, ie, nociceptive, nociplastic, or neuropathic, and to
identify specific aberrant pain mechanisms when present. e
diagnosis of nociplasticity should direct the choice of intervention.
Specifically, the physical therapist should choose interventions
that have been demonstrated to modulate impaired pain
mechanisms. Specific types of exercise as well as afferent sensory
input into the central nervous system delivered via physical
therapy interventions such as transcutaneous electrical nerve
14–16
stimulation (TENS), and manual therapy
to facilitate descending inhibitory mechanisms,
have been shown
14,16
albeit, the
evidence in PGP management is limited. Furthermore, it has
been demonstrated in an animal model that exercise facilitates
both opioidergic and serotonergic descending inhibitory
17
mechanisms.
Peripheral biomechanical concepts have also been used to
explain the effects of manual therapy. Commonly, a specific
manual therapy technique is directed at a specific segment
based on palpation and passive movement assessment. is
line of clinical reasoning used in isolation becomes problematic
because the examination process for determining the segment
to target is unreliable and relates poorly to both clinical
18
outcomes and reliable mechanical measures.
Furthermore,
there is evidence to suggest that general thrust techniques
(targeting a random spinal segment) are just as effective as
specific techniques (targeting the spinal segment believed to be
19
affected).
erefore, successful management of PGP may be
mediated via neurophysiologic mechanisms rather than altering
joint mechanics at the pelvis.
e overall intent of this monograph is to provide a
framework to assess and manage PGP while integrating
contemporary evidence. It will offer an alternative perspective
to the movement dysfunction approach as well as help clinicians
address potentially harmful beliefs about structural fragility.
12
CLINICAL ANATOMY, KINESIOLOGY,
AND BIOMECHANICS
Historically, the form and function of the pelvic girdle
has been a source of frequent debate. e goal of this section
will be to provide an overview of clinically relevant anatomy,
kinesiology, and biomechanics of the pelvic girdle. For additional
information, the reader is encouraged to refer to anatomical
texts and studies that provide a complete review of anatomy
and biomechanics. Suggested readings would include textbooks
by Frank Netter and Donald Neumann, and recommended
reviews by Poilliot et al,
Anatomy
e pelvic girdle is composed of the sacrum, right and left
ilium, ischium, pubic bones, and the coccyx. Pertinent bony
landmarks for palpation include the anterior superior iliac
spine (ASIS), pubic symphysis, posterior superior iliac spine
(PSIS), sacral base, and coccyx. e lower lumbar segments
are a common source of lumbopelvic pain and provide a direct
20
Vora et al,21 and Vleeming et al.
22
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anatomical connection to the pelvic girdle. A complex system of
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connective tissues, including multi- and single-joint muscular
attachments and capsuloligamentous structures, links these
osseous structures and creates joint interactions. Innervation to
the pelvic girdle is provided by rami from the lumbar and sacral
plexus.
Joints
e pelvic girdle accepting body weight from the trunk
above facilitates locomotion by the extremities below. e
primary points of stability in the pelvic girdle are the SIJs
and the pubic symphysis. Reviews by Poilliot et al20 and Vora
et al21 characterized the SIJs as diarthrodial, and as “highly
specialized joints that permit stable (yet flexible) support to
the upper body.”22 Individually, bony anatomy is variable and
sex differences also exist. Generally speaking, the male pelvic
girdle is longer and more narrow, and the female pelvic girdle
is shorter and wider.22 A review by Vleeming et al22 discussed
anatomical variants of interest, including the sacralization of
the fifth lumbar vertebra, a congenital anomaly that occurs
in approximately 6% of adults.
22
is sacralization can affect
the diameter of the pelvic outlet, more so in females than
males.22 Another anatomical variant described in this review
is sacrococcygeal fusion with prevalence estimates varying
throughout the lifespan.
22
e iliac surface of the SIJ has a tendency towards a “C”
shape, while the sacral surface tends towards an “L” shape
configuration (Figure 1).22 e articular surfaces of the sacrum
and ilium contain grooves and ridges that contribute to the
stability of the SIJ by increasing the coefficient of friction within
Figure 1.
Articular Surfaces
22
the joint.
is friction specifically improves stability against
shear forces. Additionally, the wider sacral base (superiorly and
anteriorly) allows the sacrum to sit firmly within the pelvic ring,
providing further resistance to shear from vertical compression,
22
while weight bearing.
e pubic symphysis is also a relevant articulation in
PGP. e pubic symphysis is nonsynovial and amphiarthrodial
in nature, with ligaments that resist all motions. A variety of
muscular attachments are nearby, including trunk and extremity
musculature, and its innervation is from various branches of the
23
lumbar and sacral nerve roots.
Research historically has used the concepts of form and
force closure to explain the possible mechanisms of stability
and mobility in the SIJ. Form closure is the theory that the
SIJ is inherently stable due to the joint surfaces fitting closely
with the sacrum wedged between the ilia and the extensive SIJ
ligamentous structures. Force closure is the theory that the
surrounding muscles and ligaments provide a compressive
24
force across the SIJ to further enhance stability.
24
Schuenke
described perfect form closure as “similar to the fit
Vleeming and
of … pieces of a puzzle … such a construct would not allow for
the joint mobility required for ambulation, activities of daily
living, and accommodations for pregnancy and childbirth.”
From this, the concept of force closure arose, as form closure
alone was insufficient to provide the balance of pelvic stability
and functional mobility. Force closure is then described as the
“effect of altered joint reaction forces generated by tension in
ligaments, fasciae, and muscles and ground reaction forces.”
24
While these theories are logical at a biomechanical level, it is
likely that the relatively small amount of motion at the SIJ
and the limitations in study design to measure such motion in
humans have contributed to a lack of contemporary research
to associate these theories directly with functional activity
limitations or improvements.
A, Ilium. B, Sacrum.
Illustration by Kinstler Design.
Capsuloligamentous tissues
Contributing to SIJ stability are ligaments on the ventral
surface of the joint, including the joint capsule, the ventral or
anterior sacroiliac ligament, and interosseous sacroiliac ligament
as well as dorsal ligaments including the thoracolumbar fascia,
the long and short dorsal SIJ ligaments, and sacrotuberous
20,22
and sacrospinous ligaments.
A review by Vleeming et al22
provided a thorough description of local ligamentous tissues
and their implications on anatomy and physiology. e long
dorsal SIJ ligament is the most superficial SIJ ligament and
is a common area of tenderness in peripartum females.
long dorsal SIJ ligament is typically palpable just inferior to
22
the PSIS.
e iliolumbar ligaments provide support to the
lumbosacral junction by restricting lumbar lateral flexion,
though studies have shown significant variation in the overall
22
anatomy (Figure 2).
e anterior sacroiliac ligament is an extension of the an-
terior-inferior portions of the SIJ capsule (Figure 3).
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20,22
22
e
e
Figure 2.
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Illustration by Kinstler Design.
Figure 3.
Anterior View of the Capsuloligamentous Tissues of the Pelvic Girdle
Posterior View of the Capsuloligamentous Tissues
of the Pelvic Girdle
SIJ capsule is relatively
thin on the anterior aspect, and therefore is susceptible to leakage during
intra-articular injection.
22
is is an important consideration when assessing
the validity of diagnostic
injections for SIJ driven
pain. If there is leakage
of the anesthetic medium
into other local pelvic tissues outside the SIJ, we
cannot be certain that the
SIJ is the primary pain
generator.
e sacrotuberous
ligament originates along
the PSIS and the entire
lateral margin of the posterior sacrum, where it
blends with the long dorsal SIJ ligament and inserts at the inferior aspect
of the ischial tuberosity.
20
e trunk and extremity
musculature attach direct-
ly to the sacrotuberous ligament, making this ligament of
particular interest when assessing response to load applied
20
through the relevant musculature (Figure 2).
ese muscular attachments and their implications are reviewed in
the next section. In a systematic review, the sacrotuberous
ligament has been identified as connected directly to the
biceps femoris, and at times can be completely fused to
20
the muscle.
Lastly, the systematic review by Poilliot et al
20
described
the thoracolumbar fascia as a connection between bony
and ligamentous landmarks of the pelvic girdle and the
surrounding trunk and extremity musculature. e
connections of these muscle groups via the thoracolumbar
fascia will be important to consider during strength and
other functional muscle assessment during the initial
examination.
Illustration by Kinstler Design.
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Muscles
As previously mentioned, various capsuloligamentous
structures, particularly the sacrotuberous ligament
and thoracolumbar fascia, provide direct anatomical
connections from the trunk and extremity musculature
to the pelvic girdle. e sacrotuberous ligament has direct
integration with the lumbar extensors, piriformis, gluteus
20,22
maximus, and the biceps femoris muscles
and the
thoracolumbar fascia provides direct connections to the erector
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spinae, latissimus dorsi, psoas major and minor, transverse
20
abdominis, and gluteus medius muscles (Figure 4).
piriformis is the only muscle that directly attaches to the SIJ.
e
20
ough the majority of muscles attaching to the pelvis
do not cross the SIJ or pubic symphysis, their respective
attachments still harbor functional implications for the pelvic
girdle. For example, the erector spinae and multifidi muscles
act to increase lumbar extension and sacral nutation, and the
gluteus maximus muscle acts to pull the sacrum laterally on the
ilium while also extending and externally rotating the hip.
22
In vivo doppler studies showed that transverse abdominis,
multifidus, erector spinae, gluteus maximus, and biceps femoris
muscle activation increased force closure and stiffness of the
SIJ. However, the doppler methodology has not been widely
used. Studies using this technique typically assess patients in
unloaded positions, and most studies have examined only
women with severe PGP and higher levels of baseline laxity,
potentially limiting generalizability.
22
Clinicians particularly should consider the impact of
weakness of the lumbar extensors, gluteals, hamstrings, and
abdominal muscles on the load distribution through the pelvic
girdle. Furthermore, while intrinsic pelvic musculature should
Figure 4.
Relevant Musculature with Direct or Indirect Attachments to the Sacroiliac
Joint
Illustration by Kinstler Design.
be evaluated, referral to a pelvic health specialist should be
considered if suspecting impairments of any of the levator ani
components, or if an internal pelvic examination is warranted.
Innervation
Innervation of the SIJ is also a source of much debate.
Reviews have demonstrated variation in innervation among
individuals for both the posterior and anterior SIJ surfaces,
though there is some agreement that the anterior SIJ is
innervated by L4-S2 branches, and the posterior SIJ by L5S4 branches.
20,22
e presence of nerve fibers presumed to be
nociceptive group IV and group III fibers has been observed,
in addition to peptidergic fibers containing substance P and
25,26
calcitonin gene-related polypeptide (CGRP),
indicating that
the SIJ is capable of nociception. After tissue injury, substance
P and CGRP are released by primary afferent fibers, both at
the peripheral nerve endings, contributing to neurogenic
27
inflammation, and at the dorsal horn.
e release of these
peptides and other inflammatory mediators may act to decrease
action potential thresholds, facilitate wind-up, and increase
excitability of nociceptive pathways, resulting in peripheral and
central nociplasticity.
27
Major nerve branches off
the lumbosacral plexus include
the obturator, femoral, and sciatic nerves, all of which may be
implicated in patients with LBP
or PGP. e obturator nerve
originates from the lumbar nerve
roots, travels along the deep inner rim of the pelvis, through
the obturator foramen, and into
the musculature of the medial
thigh. is pathway offers ample opportunity for entrapment
by the iliacus or psoas major
muscles, the obturator fascia,
and the obturator musculature.
e femoral nerve also arises
from the lumbar nerve roots,
goes through the psoas major
muscle to run between the psoas
and iliacus muscles, then exits
the pelvis inferior to the inguinal ligament. Lastly, the sciatic
nerve arises from both lumbar
and sacral nerve roots, traveling
anterior to the piriformis muscle and leaving the pelvis via the
greater sciatic foramen. Multiple sciatic nerve variants exist, in
which the nerve can be divided
above the piriformis muscle or
12
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travel through the piriformis muscle. us, peripheral neuropa-
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thy is a potential source of PGP.
e lumbar plexus and sacral plexus also contribute to
sympathetic and parasympathetic innervation of the abdominal
and pelvic viscera via the pelvic and sacral splanchnic nerves.
While visceral pain is not a musculoskeletal condition, clinicians
need to consider the possibility of visceral pain referral from
genitourinary and gastrointestinal structures and refer to other
health care providers as appropriate.
Vasculature
e common iliac arteries, internal iliac arteries, and
20
superior gluteal arteries lie in close proximity to the SIJ.
e
SIJ itself is supplied by branches of the internal iliac artery and
20
gluteal arteries.
gluteal artery stenosis causing buttock claudication,
ere have been reports of isolated superior
28
which
is a rare but possible cause of PGP. Another consideration is
disease or occlusion of the internal iliac arteries, which can lead
to claudication and therefore pain in the lower back or pelvic
girdle. Pain related to vascular claudication may masquerade
as mechanical pain during activity, and clinicians should
consider the presence of other symptoms, such as trophic
changes, temperature changes, and lower extremity pulses
when attempting to rule in or out the contribution of vascular
pathophysiology to a patient’s symptoms.
Kinesiology and Biomechanics
Motion of the SIJ is commonly referred to as nutation
29
and counternutation, in addition to translation.
ough
SIJ, a number of study limitations exist, resulting in uncertainty
and a lack of consensus on properties of SIJ motion, as well as the
connection (or lack thereof) between SIJ motion and pathology
29,30
or pain.
A systematic review by Goode et al30 examined
standard error of measurement for the given measurement
method, which, in addition to other inclusion and exclusion
criteria, resulted in 7 quality studies to be reviewed. e overall
findings of the systematic review concluded that motion of the
SIJ appears to occur on a minute level that may be “subclinically
30
detectable,” and therefore not reliably palpated by clinicians.
Nutation of the SIJ is described as decreasing during
lumbar flexion (otherwise known as counternutation), and
22
increasing during lumbar extension.
22
Vleeming et al
31
using radiostereometric analysis of implanted tantalum
et al
and in the movement studies by Sturesson
In the review by
balls in the pelvis, the authors concluded that sacral nutation
tends to occur with transfers from supine to sitting or standing,
and that SIJ movement does not differ between symptomatic
22,31,32
and asymptomatic sides.
Additionally, these studies
have demonstrated that SIJ movement decreases as joint
22,31,32
load increases.
ough studies have examined various
directions of SIJ movement in differing load positions, mobility
about the transverse axis (S2) appears to be the most significant
motion.
12,22
e review by Vleeming et al22 also included discussion of
studies involving surgically implanted Kirschner rods in healthy
individuals, who showed an average of 2° total SIJ rotation
22
when shifting from both feet to single leg stance.
Further, no
differences were found between age groups, sex, or between
22
women with and without children.
Cibulka et al33 assessed
innominate tilt during reciprocal stance in patients with and
without SIJ pain and found a possible coupling failure in patients
with SIJ pain; however, the study was limited due to palpation
by only one examiner using external calipers, allowing for only
simple measurements of innominate mobility.
e pelvic girdle is inherently linked to the lumbar spine
29
and the lower extremities. Hammer et al
studied in vitro SIJ
motion and found small amounts of motion around all axes when
loading via both femurs and through the fifth lumbar vertebra.
is was in agreement with in vivo findings from Kibsgård
34
who assessed SIJ movement using tantalum markers in
et al
patients with chronic SIJ pain performing an active straight
leg raise (ASLR). During the ASLR, the authors found a small
posterior rotation of the innominate of the resting leg relative
to the sacrum, with nearly zero rotation of the innominate in
35,36
the lifting leg, contradicting earlier studies
that indicated
forward innominate rotation of the lifting leg. Overall, studies
show conflicting findings of typically only small motion in
the SIJ; thus, in the absence of valid and reliable clinical tests
to assess SIJ mobility, it is challenging to use presumed SIJ
hypermobility or hypomobility to drive differential diagnosis,
examination planning, or clinical intervention decisions.
In conclusion, presence or absence of SIJ hypomobility or
hypermobility is likely less contributory to the pain experience
than has been described previously. Reviews of studies on
the SIJ have found considerable individual variation in joint
anatomy and mobility, indicating that asymmetries in SIJ
22
anatomy and mobility are normal.
Considering these normal
variations, clinicians should be cautious when educating
patients on examination findings, and avoid language
suggestive of malpositioning or instability that could promote
fear avoidance, kinesiophobia, or maladaptive health beliefs.
Emphasis should be placed on reassuring the patient of the
inherent strength and stability of the spine and pelvic girdle and
avoiding the use of explicit or implicit terminology suggestive
of hypomobility or hypermobility. ere will be exceptions
to this guidance, for example, in the case of patients during
pregnancy who are experiencing pubic symphysis separation,
but the overarching education given to patients should focus
on patient empowerment and functional goals. With regard to
understanding and explaining the patient’s pain experience, it
is important to go beyond these anatomical and biomechanical
considerations and seek to understand the psychosocial
contributors and neurophysiologic mechanisms that contribute
to the pain presentation.
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For personal use only. No other uses without permission.
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13
MECHANISMS OF CHRONIC
https://t.me/med1917
PELVIC GIRDLE PAIN
A common denominator of both SIJ and PGP is that both
are often chronic in nature, and as a result, central nociplasticity
may be a prominent feature.
diagnosis of pelvic pain is challenging. Clinically, altered
nociceptive processing presents as positive or negative sensory
findings, often measured via quantitative sensory testing (QST).
Positive findings may include enhanced responses to stimuli
such as hyperalgesia or dysesthesia, while negative findings may
include reduced responses to sensory stimuli.
A conspicuous difference is noted in QST studies in
individuals classified as having SIJ pain compared to those
with PGP, including peripartum pelvic pain. Van Leeuwen et
39
examined pressure pain thresholds (PPTs) in the sacroiliac
al
region in persons with SIJ pain and matched healthy controls,
and found lower PPTs in the group with SIJ pain. Testing
PPT is often used in chronic pain populations to determine
which classification of pain mechanism may be involved, with
the specific purpose of identifying local (primary) hyperalgesia
and the potential spread of hyperalgesia, which may indicate
secondary hyperalgesia, and therefore, central nociplasticity.
In the study by Van Leeuwen et al,
were not examined; thus, the potential of expanded regional
or widespread hyperalgesia could not be determined. is was
also examined in an experimental pain paradigm, where pain
was induced in the long dorsal SIJ ligament by injection of
41
hypertonic saline.
e study demonstrated that pain induced
in a superficial structure in the SIJ complex was capable of pain
referral similar to that of intraarticular pain. Furthermore, SIJ
provocation tests, which have been used to rule in articular
42
SIJ pain,
were positive in this study. Interestingly, PPTs at
the gastrocnemius muscle were not diminished, potentially
indicating a lack of secondary hyperalgesia spreading into the
lower limb. is is not altogether surprising considering the
use of an acute experimental pain paradigm. In a lumbar facet
model, longer duration of experimental pain (10 minutes)
resulted in an increasingly expanded report of pain into the
lower limb, but PPTs in the lower limb were unchanged.
ese studies highlight a clinical phenomenon that occurs with
central nociplasticity, specifically that expanded distribution of
symptoms may occur with greater chronicity of a condition.
During pregnancy, widespread deep-tissue hypersensitivity,
measured via QST, has been shown to be associated with
44,45
lumbopelvic pain.
Palsson et al45 demonstrated that
pregnant women with lumbopelvic pain had positive findings
on SIJ pain provocation tests, and those with more severe pain
had more difficulty with the ASLR test; however, none of the
participants demonstrated signs of allodynia. Several factors
may contribute to heightened levels of lumbopelvic pain during
pregnancy, including poor sleep hygiene and psychosocial
factors, particularly those addressed on the Tampa Scale of
Kinesiophobia such as fear of movement, fear of physical
37
Accordingly, the differential
38
39
regions outside of the SIJ
40
43
46
activity, and fear-avoidance behaviors.
Heightened levels of
pain in chronic conditions have also been attributed to central
nociplasticity.
Although not traditionally included with SIJ pain and
PGP, visceral conditions such as painful bladder syndrome,
dysmenorrhea, endometriosis, irritable bowel syndrome,
interstitial cystitis, vulvodynia, or vestibulodynia are recognized
47–51
as potential significant sources of chronic lumbopelvic pain.
Several studies have performed investigations using QST for
the purpose of understanding the underlying mechanisms of
47–51
persistent pain in individuals with these conditions.
It has
been suggested that significant overlap exists between visceral
52
and somatic chronic conditions,
thus, it seems appropriate
to take a broader view of management of SIJ pain and PGP.
Studies have demonstrated widespread somatic pain and
48
increased visceral sensitivity in these conditions.
e results of dynamic tests of central nociplasticity
have also been reported. In chronic pelvic pain conditions
of provoked vestibulodynia and painful bladder syndrome,
inefficient inhibition of pain, measured via conditioned
53
pain modulation (CPM), was demonstrated.
stronger perceptions of illness chronicity were correlated with
less efficient CPM and increased mechanical pain intensity.
In addition,
54
Cutaneous allodynia appears to have the greatest likelihood of
identifying a visceral source of pain compared to somatic sources
55
of pain.
Accordingly, enhanced temporal summation has also
been demonstrated in individuals with pelvic pain. Women
with chronic pelvic pain and allodynia showed a statistically
significant increase in pain with repetitive strokes of a cotton-
56
tipped applicator
(ie, dynamic cutaneous allodynia testing57).
In clinical practice, it is critical for the physical therapist to be
able to identify patient symptoms that necessitate referral to
a physician for medical management. Referral to a physician
would be warranted with the presence of symptoms detailed in
Table 1 combined with positive findings on dynamic tests of
central nociplasticity because this combination may suggest a
visceral source of pain.
CLINICAL EXAMINATION AND
DECISION-MAKING PROCEDURES
History and Interview
Pain diagram
True SIJ pain typically presents in the region inferior to
the PSIS. Fortin et al
just inferior to the PSIS, to be specific for SIJ pain. A later
study described that referral from the SIJ may be located in the
lower lumbar spine, buttock, groin, and medial, lateral, and
posterior thigh and sometimes in the calf.
that the variable patterns of pain referral observed may arise due
to the joint’s complex innervation, sclerotomal pain referral,
irritation of adjacent structures, and varying locations of injury
within the SIJ.
central nociplasticity indicates that secondary hyperalgesia
58
found a composite area of 3 x 10 cm,
59
It was proposed
59
However, a more recent understanding of
14
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For personal use only. No other uses without permission.
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