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Table 1.

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Symptoms in the Patient with Chronic Pelvic Pain that may Warrant Physician Referral*

Symptoms Possible signiﬁcance

Pain ﬂuctuates with menstrual cycle Adenomyosis, endometriosis Pain ﬂuctuation unassociated with menstrual cycle Adhesions, interstitial cystitis, irritable bowel syndrome Pain with urge to void Interstitial cystitis, urethral syndrome Postcoital bleeding Cervical cancer Postmenopausal bleeding Endometrial cancer Postmenopausal onset of pain Malignancy Prior abdominal surgery or infection Adhesions Unexplained weight loss Malignancy, systemic illness

*Adapted from Speer LM, Mushkbar S, Erbele T. Chronic pelvic pain in women. Am Fam Physician. 2016;93(5):380-387.

occurs, presenting as a spreading of symptoms, typically in a distal distribution.

van der Wurﬀ et al60 demonstrated that referred pain maps were not useful to discriminate pain due to the SIJ as compared to other sources of pain in chronic LBP because the distribution and size of pain referral areas were similar in responders and non-responders. However, intensity maps were helpful in diﬀerentiating between the groups. It may be concluded that patients with SIJ pain are less likely to experience pain in both the Fortin and ischial tuberosity areas; however, pain in the Fortin area with exclusion of pain in the tuberosity is most likely to be of SIJ origin.

History and behavior of symptoms

After establishing the main problem and recording a pain diagram, the history and behavior of symptoms should be explored. Clinical reasoning guides the physical therapist on which of these to explore ﬁrst. If the injury is acute, it may be more beneﬁcial to start with history to better understand the mechanism of injury and the current symptoms. However, if the pain is chronic, it may be more beneﬁcial to understand the type and behavior of pain, before gathering the patient’s prolonged history. e history of symptoms may include but is not limited to history of the present problem, past history, and predisposing factors. History of the present problem may include questions about the mechanism of injury, time since onset, changes in symptoms since onset, and treatment since onset. Questions about past history may include if the patient has had similar previous symptoms, any other previous injuries, how long it took to resolve, was previous therapy received and did it help or not. Questions related to behavior of symptoms should include aggravating and easing factors of pain, 24hour pattern, severity, irritability, nature, duration, and acute

versus chronic. Predisposing factors may include both medical and personal factors. Clinical practice guidelines for PGP in the antepartum population suggest that clinicians should consider the following negative risk factors when determining the prognosis of PGP: prior history of pregnancy, orthopedic dysfunctions, higher body mass index, smoking, as well as work dissatisfaction and a lack of belief in improvement.

Diﬀerential diagnosis

Screening for red ﬂags and the decision to refer to another health care provider has long been an important part of the physical therapy clinical examination.

Prevalence of serious pathology in patients with LBP is low; however, most patients (80.4%) presenting with acute LBP have at least 1 red ﬂag ﬁnding, making stand-alone red ﬂag questions uninformative.

erefore, a nuanced approach to red ﬂag screening is preferable for patients with PGP.

Knowing that a red ﬂag ﬁnding will most likely be present for most patients with LBP, physical therapists should evaluate ﬁndings carefully, but keep in mind the low prevalence of serious pathology. narrative review

described the pitfalls associated with red

A more recent

ﬂag screening and provides alternatives. e review suggested watchful waiting as opposed to costly testing, and linking symptoms to outcomes rather than to pathology because early diagnostic imaging testing is very likely to exaggerate potential pathology.

Premkumar et al66 proposed that clinicians use caution when using red ﬂag questions as screening tools because negative responses do not meaningfully decrease the likelihood of a red ﬂag diagnosis.

Some speciﬁc individual red ﬂags and combinations of red ﬂags have been associated with an increased probability of underlying serious spinal pathology.

e individual and combination of diagnostic associations in

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Table 2 should be considered when evaluating individuals with pelvic girdle pathology.

e International Federation of Orthopedic Manipulative Physical erapists recently released an international framework to help guide health care professionals, including physical

therapists, identify potential serious spinal pathologies.

While detailing the framework is beyond the scope of this monograph, the framework does reinforce the idea that red ﬂags used in isolation are uninformative. e framework can be a useful tool to help clinicians identify and evaluate the relevance of red ﬂags within the context of the patient’s health proﬁle, as well as in combination with a thorough history intake and clinical examination.

In addition to maintaining awareness of red ﬂags as potential sources of LBP, it is important to keep in mind that individuals with LBP or PGP often have complex histories where psychological, social, and biophysical factors, comorbidities, and altered pain processing impact both the pain experience and the associated self-reported disability.

ese diverse problems are often referred to as yellow ﬂags.

e term yellow ﬂag, originally coined by Kendall et al,

is used to describe psychological, social, and environmental risk factors for prolonged disability and failure to return to work as

a consequence of musculoskeletal symptoms.

While multiple studies have shown that psychological factors may be more strongly associated with increased pain intensity, increased

health care consumption, and increased disability, yellow ﬂags are not assessed routinely as a standard part of orthopaedic

69–71

physical therapy practice.

It has been proposed that the lack of assessment is due to clinician uncertainty about what speciﬁc psychological factors to assess as well as how best to manage

them once identiﬁed.

As a result, a recent tool was developed to address this gap in clinical care. is multidimensional yellow ﬂag assessment tool is inclusive of both vulnerability and resilience factors for application in orthopaedic physical

therapy clinical practice.

is tool, the Optimal Screening for Prediction of Referral and Outcome-Yellow Flag (OSPROYF), was found to be a reliable and valid multidimensional psychological assessment instrument for individuals with

musculoskeletal pain.

Implementation of the OSPRO-YF may

better guide clinical decision making and may lead to improved

musculoskeletal pain management strategies (Table 3).

A useful tool for the clinician is the OSPRO-YF Assessment Tool Scoring Portal where clinicians can enter the results of the OSPRO-YF and receive interpretation of the results. is tool can be found on the Academy of Orthopaedic Physical erapy website (https://www.orthopt.org/yf/).

e occupational component of yellow ﬂags can be further delineated into blue and black ﬂags. Blue ﬂags are relevant in terms of the employee and the workplace, with features of work generally causing an increase in symptoms. Examples include high demand and low control, unhelpful management style, poor social support from colleagues, perceived time pressure,

Table 2.

Individual and Combination of Red Flags to be Considered in Pelvic Girdle Pain*

Pathology Diagnostic association PLR NLR Combination of associations PLR NLR

Fracture Trauma

Age >50 Age >70

Malignancy History of cancer

Unexplained weight loss Pain awaken from sleep Age > 50 Age > 70

Infection Fever, chills, or sweating

Recent infection Pain awaken from sleep Persistent sweat at night

Cauda equina syndrome

Abbreviations: NLR, negative likelihood ratio; PLR, postive likelihood ratio *Adapted from Premkumar A, Godfrey W, Gottschalk MB, Boden SD. Red ﬂags for low back pain are not always really red: a prospective evaluation of the clinical utility of commonly used screening questions for low back pain. J Bone Joint Surg Am. 2018;100(5):368-374.

Recent loss of bowel control Recent loss of bladder control

2.17

1.1

1.55

7.25

1.87

0.85

1.06

1.1

1.71

9.31

0.99

1.26

2.78

2.31

0.84

0.79

0.86

0.71

0.96

1.07

0.87

0.97

0.95

0.78

1.02

0.96

0.91

0.86

Trauma & age >50 Trauma & age >70

Unexplained weight loss and history of cancer

Fever, chills, or sweating and recent infection

Recent loss of bowel and bladder control

2.54

4.35

0.90

0.96

10.25 0.98

13.15 0.93

3.0 0.94

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

and lack of job satisfaction.74 Black ﬂags are similar to blue ﬂags;

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however, they are related more to established policy concerning work conditions, which are out of the immediate control of the employee. Examples include rates of pay, negotiated entitlements (beneﬁts, etc), sickness policy, restricted duties policy, organization size and structure, trade union support, ergonomics, and temporal characteristics such as duration of work shift (Table 3). A recent study found that work-family imbalance, exposure to hostile work environment, and job insecurity were associated with LBP after adjusting for diﬀerent demographic, socioeconomic, and occupational factors.

Additionally, long work hours were associated with an increased risk of LBP.

Based on these ﬁndings it is suggested that it is important to screen for these factors during the history and interview process.

While most of these studies were performed in a patient population with LBP, PGP as a subset of LBP should be managed in a similar manner. Additionally, the European guidelines for the diagnosis and treatment of PGP

suggests that there is no diﬀerence between LBP and PGP, except that patients with PGP are normally younger than 30 years old and therefore are less likely to have malignant diseases, ie, red ﬂags, as the cause of pain. e role of yellow ﬂags has not been investigated among patients with PGP but, based on the present limited knowledge, the impression is that yellow ﬂags are less common among patients with PGP than among those with LBP.

e European guidelines do not discuss blue and black ﬂags in connection with PGP.

Patients with PGP should be asked precautionary questions related but not limited to medical history and comorbidities, surgical history, imaging or blood work related to the current condition, current medication, use of drugs or alcohol, work duties, exercise, and sleep hygiene. A further review of systems may be warranted based on the answers to precautionary questions or the description of pain. A more detailed review of systems may include but is not limited to screening for spinal cord compression, cardiovascular health, gastrointestinal health, genitourinary health, and reproductive and sexual health (Table

4).

Examination and Assessment

Clinical decision-making process

Based on the European guidelines for the diagnosis and treatment of PGP, the diagnosis of PGP can be reached after exclusion of the lumbar spine and hip joint as a source of symptoms, but only if the pain or functional disturbances related to PGP are reproducible by speciﬁc clinical tests.

With guidance from the clinical practice guidelines for the

76,77

hip,

low back,78 and PGP in the antepartum population,61 an algorithm (Figure 5) was created that details the clinical reasoning and procedures that should be included in the examination of individuals with suspected PGP. While it may not be possible to complete all examination measures due to patients’ irritability, time constraints, or other factors, Figure

Table 3.

Yellow, Blue, and Black Flags to Consider with Pelvic Girdle Pain

Flag Deﬁnition Examples

Yellow Psychological risk factors and social and

environmental risk factors for prolonged disability and failure to return to work

Negative mood (depression, anxiety, anger) Fear-avoidance (fear-avoidance beliefs, catastrophizing, kinesio-

phobia, and pain-anxiety) Aﬀect/coping (pain self-eﬃcacy, rehabilitation self-eﬃcacy, and

chronic pain self-eﬃcacy; and chronic pain acceptance)

Blue

Relates to the employee and the workplace, features of work can cause an increase in symptoms

High demand and low control Unhelpful management style Poor social support from colleagues Perceived time pressure and lack of job satisfaction

Black

Relates to established policy concerning work conditions out of the immediate control of the employee

Rates of pay Negotiated entitlements (beneﬁts, etc) Sickness policy Restricted duties policy Organization size and structure Trade union support Ergonomics Temporal characteristic such as length of shift

Table 4.

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Detailed Review of Systems*

System Questions

Cardio/peripheral vascular system (CVS)

Dyspnea Orthopnea Palpitations Pain/sweats Syncope Peripheral edema Cold hands/feet Skin discoloration Open wounds/gangrene Cough

Gastrointestinal system (GIS)

Diﬃculty with swallowing Heartburn, indigestion Speciﬁc food intolerance Change in appetite Bowel dysfunction including color, frequency, shape, constipation, diarrhea, diﬃculty initiating, and incontinence

Urinary system (US) Frequency

Urgency Incontinence Reduced caliber or force of urine

making and oﬀers a suggestion for an examination sequence.

Screening the hip and the lumbar spine (Appendix A) is performed to identify potential impairments and ‘rule out’ these regions as a possible source of pain. is includes active range of motion (AROM) with overpressure, accessory motion assessment, and special tests as required. It is imperative that the lumbar spine and hip joint complex are screened prior to making the diagnosis of SIJ pain or PGP.

Palpation-based mobility tests

It is important to acknowledge the historical use of palpation-based mobility tests and review evidence about their continued use, which seems to support discontinuing

their use. A recent systematic review

suggested that the use of SIJ mobility tests in clinical practice, alone or in clusters, is problematic because of the low and or imprecise reliability estimates, the absence of high-quality diagnostic accuracy studies, and the uncertainty regarding the construct these tests aim to measure. Despite the lack of evidence to support palpation-based mobility testing, a recent collaborative model of PGP suggests there is still a bias towards using a biomechanical approach in clinical

practice today.

To properly examine and manage PGP, a

more integrative approach needs to be implemented.

Diﬃculty initiating urine stream Color Dysuria

Genital reproductive system (GRS) Male

Urethral discharge Impotence Pain with intercourse/ejaculation

Female

Vaginal discharge Pain with intercourse Change in menstruation Frequency and length of cycle Dysmenorrhea Blood ﬂow Date of last period Number of pregnancies Number of deliveries Menopause Perimenopausal

Postmenopausal vaginal bleeding/spotting

*Adapted from Boissonnault WG, ed. Examination in Physical erapy Practice: Screening for Medical Disease. 2nd ed. Philadelphia, PA: Churchill Livingstone; 1995.

Pain provocation tests

In addition to palpation-based mobility tests, pain provocation tests (Table 5) have long been used to assess the SIJ as a potential pain generator. It seems reasonable to propose that stress testing of the SIJ would provoke pain of SIJ origin; however, with sensitization of tissues, provocation of symptoms does not always imply structural fault. us,

Laslett at al

proposed that clustering provocative tests would improve diagnostic value. e authors determined that reproduction of pain or symptoms with 3 or more of 6 tests (thigh thrust, compression, distraction, sacral thrust, Gaenslen right, Gaenslen left) or any 2 of 4 selected tests (thigh thrust, compression, distraction, sacral thrust) had the best diagnostic ability when using intra-articular anesthetic block injections as the gold standard. When none of the 6 provocation tests provoke familiar pain,

the SIJ can be ruled out as a source of current LBP.

later study by van der Wurﬀ et al

of Laslett et al.

e reproduction of pain with at least

supported the ﬁndings

3 of 5 physical examination maneuvers (thigh thrust, Gaenslen, ﬂexion/abduction/external rotation [FABER], distraction, and compression) was found to have a positive likelihood ratio of 4.02, and 0 of 5 positive physical examination maneuvers had a negative likelihood ratio

of 0.00.

However, a more recent study examining the

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

Figure 5.

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Decision Tree to Help Guide Clinical Reasoning During a Pelvic Girdle

Examination

Clinical

examination

of pelvic

girdle pain

Preliminary

red flag

Positive Negative

Immediate

referral

Neurological examination

Abbreviations: ASLR, active straight leg raise; GI, gastrointestinal; GU, genitourinary; MMT, manual muscle test; ROM, range of motion; SIJ, sacroiliac joint

Refer, but

proceed with

caution

Detailed

subjective &

objective

screening

Abdominal

examination

If examination or

questions are

unremarkable,

proceed to objective

examination

screening

GU, GI,

reproductive

systems

questions

If findings are

concerning, consider

immediate referral

Objective

examination

Symptom provoking functional activities

Gait, physical

performance

measures

Lumbar & hip screen,

including ROM,

accessory

movements, and

special tests

SIJ pain provocation

cluster

(Compression,

Distraction, Thigh

Thrust, Sacral Thrust,

Gaenslen's)

Other SIJ tests

(Lunge, ASLR,

Mennell's)

MMT

Palpation

Specific Pelvic Girdle

Pathology

Pregnancy-related

Pelvic Girdle Pain

Non-specific Pelvic

and guide treatment

Interpret findings to classify pain

Girdle Pain

Nociplastic Pelvic

Girdle Pain

validity of 6 physical examination maneuvers (thigh thrust, Gaenslen, FABER, distraction, compression, and sacral thrust) found that these tests did not demonstrate diagnostic value, either individually or in combination, when compared with the reference standard of an intra-articular anesthetic block.

ese ﬁndings are similar to those found earlier by Dreyfuss et

where no single maneuver or combination of examination

al maneuvers was associated with response to the diagnostic

injection, which is in contrast to ﬁndings by Laslett et al

van der Wurﬀ et al.

Using an intra-articular injection as a

and

reference standard is a limitation of the above studies because the SIJ capsule is relatively thin on the anterior aspect, and therefore is prone to possible leakage of the injected material.

Neurological examination

e pelvic ﬂoor is innervated by the pudendal nerve, formed in the lower division of the lumbosacral plexus from portions of the S2–4 nerve roots. e levator ani muscles are innervated by the levator ani nerve, originating from the S3–5 foramina. Autonomic innervation allows for coordinated function of the pelvic viscera. An important early decision in the diﬀerential diagnosis of lumbopelvic pain is the determination whether the pain is neuropathic or non-neuropathic. It is recommended that clinicians use written tools such as the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS)

e contrasting ﬁndings between these studies suggest more research is needed to determine the eﬀectiveness of pain provocation tests in diagnosing SIJ dysfunction. However, after carefully ruling out red ﬂags, and lumbar spine, hip joint, and visceral sources of pain, the authors of this monograph suggest that the clinician can cautiously use pain provocation tests to investigate the SIJ as a potential source of pain.

Abdominal examination

Because pain referral to the lumbopelvic region is not uncommon in visceral disorders, clinicians should consider including an abdominal examination as part of the assessment process. e examination can be performed with the patient supine with a pillow under the knees to relax the abdominal muscles. e examination should include inspection of the skin, auscultation for bowel and vascular sounds, superﬁcial and deep palpation of visceral structures, percussion of the liver, spleen, and kidney, as well as examination of the abdominal aorta for pulsation and width.

Table 5.

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Pain Provocation Tests to Assess the Sacroiliac Joint (SIJ) as a Potential Pain Generator

Test Description Image

167

 igh thrust

 e patient lies supine with the hip and knee ﬂ exed where the thigh is at a right angle to the table and slightly adducted. One of the examiner’s hands cups the sacrum and the other arm and hand wraps around the ﬂ exed knee.  e pressure is applied directed along the line of the vertically oriented femur.  e procedure is performed on both sides.  e presumed action is a posterior shearing force to the SIJ on that side. A positive test is reproduction of the patient’s pain.

Gaenslen

167

 e patient lies supine near the edge of the table. One leg hangs over the edge of the table and the other hip and knee are ﬂ exed towards the patient’s chest.  e examiner applies ﬁ rm pressure to the knee being ﬂ exed to the patient’s chest and a counter pressure is applied to the knee of the hanging leg, towards the ﬂ oor.  e procedure is performed on both sides.  e presumed action is a posterior rotation force to the SIJ on the side of the ﬂ exed hip and knee, and an anterior rotation force of the SIJ on the side of the hanging leg. A positive test is reproduction of the patient’s pain.

103

FABER

 e patient is supine and the hip of the involved side is simultaneously ﬂ exed, abducted, and externally rotated by the examiner so that the patient’s lateral ankle comes to rest on the uninvolved lower extremity just proximal to the knee. While stabilizing the anterior superior iliac spine on the uninvolved side, the knee of the patient’s involved lower extremity is lowered towards the table, with simultaneous external rotation and abduction, until end range of motion is achieved. From this point the examiner applies 3 to 5 small-amplitude oscillations at end range into resistance.  e presumed eﬀ ect is stress on the SIJ as the

horizontal abduction force goes through the femur, thus the tensioned soft tissues transfer the forces to the SIJ. A

positive test for SIJ involvement would be reproduction of pain posteriorly.

167

Distraction

 e patient lies supine and the examiner applies a posteriorly directed force to both anterior superior iliac spines.  e presumed eﬀ ect is a distraction of the anterior aspects of the SIJ. A positive test is reproduction of the patient’s pain.

Academy of Orthopaedic Physical  erapy, APTA.

For personal use only. No other uses without permission.

Table 5.

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Continued

Test Description Image

167

Compression

 e patient lies on the side with hips and knees slightly ﬂ exed.  e examiner applies a force vertically downward on the uppermost iliac crest.  e presumed action is a compression force to both SIJs. A positive test is reproduction of the patient’s pain.

Sacral thrust

167

Active straight leg raise

 e patient lies face down.  e examiner applies a force vertically downward to the center of the sacrum.  e presumed action is an anterior shearing force of the sacrum on both ilia. A positive test is reproduction of the patient’s pain.

 e test is performed with the patient in a supine position with legs straight and feet slightly apart.  e therapist provides verbal instructions: “Try to raise your leg, one after the other, above the table without bending the knee.”  is is done without providing manual assistance (not illustrated).  en, the test is repeated while the therapist provides manual stabilization across the pelvis through the iliac crests (illustrated).

For each leg and for both versions of the test, the patient is asked to score their diﬃ culty on a 6-point scale:

0 = not diﬃ cult at all 1 = minimally diﬃ cult 2 = somewhat diﬃ cult 3 = fairly diﬃ cult 4 = very diﬃ cult 5 = unable to do

 e presumed eﬀ ect is the action of the hip ﬂ exors during the straight leg raise causing rotational shear at the SIJ and that providing manual stabilization helps control these rotational shear forces. In addition to the diﬃ culty rating, a positive test would be greater ease and/or reduced pain when the test is performed with manual stabilization from the therapist.

Table 5.

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Continued

Test Description Image

Lunge

107

 e patient performs a standard lunge bilaterally.  e presumed eﬀ ect is a posterior rotation force to the SIJ on the side of the ﬂ exed hip (front leg) and an anterior rotation force of the SIJ on the hip in neutral (back leg).  is is similar to Gaenslen test, however in a weight bearing position. A positive test would be reproduction of pain.

Abbreviation: SIJ, sacroiliac joint

or the Pain Detect85 questionnaires to aid in this decision-making process. A neurological examination is also indicated, including assessment of cutaneous sensation, myotomes, and upper motor neuron and deep tendon reﬂ exes. For the pelvic ﬂ oor (Figure

6), the important sensory dermatomes are L1 (base of penis, upper scrotum), L1-2 (mid-scrotum, labia-minora), L3 (front of knee), S1 (sole and lateral area of the foot), S1-3 (perineum and circumanal skin), and S2-5 (both the external urethral and the anal sphincter).

Reﬂ exes are assessed to evaluate excitability of upper and lower motor neurons. Deep tendon reﬂ exes include the patellar reﬂ ex (L3, L4) and the Achilles tendon reﬂ ex (L5, S1, S2). In patients with upper motor neuron lesions, the deep tendon reﬂ exes are hyperactive and Babinski sign is positive (dorsiﬂ exion of the great toe in response to a dynamic noxious stimulus applied to the plantar surface of the foot).  is often is associated with bladder overactivity. Conversely, lower motor neuron lesions involving the cauda equina or lumbosacral plexus often result in hypoactive deep tendon reﬂ exes, a negative Babinski sign, and can be associated with a hypoactive or a contractile bladder.

 e sensory examination includes cutaneous sacral reﬂ exes.  e anal reﬂ ex (S2-5) is stimulated by light stroking of perianal tissues.  e presence of voluntary anal sphincter contraction indicates functioning pelvic ﬂ oor innervation and sphincter muscle.  e bulbocavernosus reﬂ ex tests the innervation of all perineal striated muscles.  is is a local sacral spinal cord reﬂ ex arc reﬂ ecting activity in S2-4. It is elicited by squeezing the

penis gland, or clitoris, which causes a reﬂ ex contraction of the external anal sphincter.

Absence of this reﬂ ex could indicate sacral nerve damage. Allodynia may be present and can be assessed by dynamic brushing of the skin with a cotton-tipped

Figure 6.

Illustration by Kinstler Design.

Innervation of the Perineum

Academy of Orthopaedic Physical  erapy, APTA.

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applicator.87 Allodynia and facilitated temporal summation have

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been demonstrated in individuals with chronic pelvic pain.

Clinicians should also consider when to refer patients to a pelvic health specialist. Certain conditions may require an internal examination of the pelvic ﬂoor musculature, which is considered outside the scope of practice of a physical therapist without advanced training. One option for further training is clinical specialization through the Academy of Pelvic Health Physical erapy, which is available through the American Physical erapy Association.

CONDITION-SPECIFIC EVIDENCE-BASED REHABILITATION CONCEPTS

Pelvic girdle pain may be organized into 4 broad categories: speciﬁc pathologies, PRPGP, nonspeciﬁc PGP, and nociplastic PGP. It is important to note that these are not mutually exclusive and suggested interventions for one category may beneﬁt conditions in other categories. While a movementbased classiﬁcation strategy management of LBP, a recent systematic review of quality data when comparing a movement-based approach to standard care for patients with chronic LBP. As a subset of LBP, the movement-based classiﬁcation should be considered when determining the plan of care for individuals with PGP, recognizing its potential limitations and that the PGP clinical presentation may not ﬁt into this classiﬁcation system.

Specic Pathologies

Sacral stress fractures

In their systematic review, Yoder et al on this topic and divided sacral stress fractures into insuﬃciency and fatigue fractures. e mean age for insuﬃciency fractures was 70.5 years and the most prevalent identiﬁed risk factors were post-menopausal status, older age, female sex with a history of osteoporosis, and history of pelvic radiation therapy, rheumatoid arthritis, and/or long-term corticosteroid therapy. Symptom onset is usually sudden and pain may be of such intensity that walking is very diﬃcult.

For fatigue fractures, the mean age was 25.1 years with risk factors being increased training intensity and a deﬁcient diet.

ough some

have referred to female sex being a risk factor

for fatigue fractures, it was not identiﬁed as such by Yoder et

Pain is typically described as having a more gradual onset

al. corresponding to an increasing training load.

In both fatigue and insuﬃciency fractures, pain is located primarily in the lumbar spine and buttock area, although some individuals report hip and groin pain as well, and is worsened with weight bearing. On clinical examination, the most concordant sign was pain on palpation over the sacrum or SIJ. Magnetic resonance imaging (MRI) was deemed the best imaging tool to conﬁrm diagnosis.

e role of the physical therapist in managing sacral stress fractures revolves around appropriate load management.

has been suggested for directing

found a lack

reviewed 32 papers

Individuals with insuﬃciency fractures may need an assistive device to help unload the sacroiliac and pelvic region in the initial stages of healing. Similarly, reduction of load is also the key to managing those with fatigue fractures, and involves signiﬁcant reduction in training. Both groups of patients may need to consult a nutritionist to identify any deﬁciencies in their diet that may be contributing to their condition.

Axial spondyloarthritis

Axial spondyloarthritis (axSpA) comprises a group of

inﬂammatory diseases that aﬀect the spine and are often

associated with additional extra-articular conditions.

In recent years axSpA has been classiﬁed into 2 broad groups, non-radiographic (nr-axSpA) and radiographic (axSpA),

93,94

more commonly known as ankylosing spondylitis (AS).

general, AS is regarded as a progression of nr-axSpA, although

this does not always occur.

Both nr-axSpA and AS frequently involve the SIJ, so clinicians should consider this as a cause of symptoms when evaluating an individual who presents with pain in this area.

Individuals with both types of axSpA are usually under the age of 40 with a long duration of symptoms that include morning pain (especially in the buttock) and stiﬀness of the spine as well

as fatigue.

ough traditionally thought to be a disease that

aﬀects mainly males, up to one-third of those aﬀected may be

female.

Patients may also complain of pain in other joints,

tendon insertion pain, eye irritation, or inﬂammatory bowel

disease.

If a diagnosis of axSpA has already been established and the patient is reporting acute spinal pain, vertebral fracture should be considered because this is a common complication of axSpA due to its association with low bone mineral density,

particularly in those individuals with AS.

On evaluation, loss of spinal motion is noted

and pain is reproduced with provocative tests aimed at the SIJ. Pain provocation tests are more informative than functional tests when attempting to identify patients with nr-axSpA.

ese tests, in particular, the FABER test, have been shown to correlate modestly (sensitivity 71%, speciﬁcity 75%, positive likelihood ratio 2.9, negative likelihood ratio 0.4) with MRI-identiﬁed inﬂammation in individuals with nr-axSpA.

On radiographs, individuals with AS will have areas of sclerosis at the SIJ that may progress to complete fusion. By deﬁnition, those with nr-axSpA will have no such ﬁndings on radiographs, although MRI may show inﬂammation and bone

94,97

marrow edema.

Blood tests may reveal increased levels of inﬂammatory markers of C-reactive protein and erythrocyte sedimentation rate. Human leukocyte antigen B27 (HLA-B27), which typically is present in only 5% to 15% of the general population, is found in 85% to 90% of those with AS.

Although non-steroidal anti-inﬂammatories and biologic drugs such as tumor necrosis factor (TNF) inhibitors are a central aspect of medically managing axSpA, combining pharmacology with physical rehabilitation is likely to provide a

greater beneﬁt for the patient.93 In physical therapy, extension

https://t.me/med1917

exercises have been shown to be beneﬁcial for axSpA.

Perotta et al

concluded in their review that cardiovascular and

Also,

strengthening exercises may yield better outcomes compared to more traditional treatment such as postural correction, stretching, and breathing exercises. In particular, high intensity exercise may give the most beneﬁt not only for decreasing pain and improving overall quality of life but also for reducing the disease progression itself.

99,100

Osteitis condensans ilii

Osteitis condensans ilii (OCI) is a non-inﬂammatory condition characterized by sclerotic bone lesions aﬀecting the iliac surfaces of the SIJs; discovery of these may be an incidental radiological ﬁnding because many individuals with

101

this ﬁnding are asymptomatic.

It diﬀers from axSpA in that there is no joint space narrowing or eventual joint ankylosis. is condition most frequently aﬀects parous females in their fourth decade. ere are no known published trials for physical therapy treatment of OCI, so an impairment-based approach is recommended.

Pregnancy-related Pelvic Girdle Pain

Assessment

Physical therapists often encounter clients with PRPGP. e prevalence of this condition is quite high particularly when combined with LBP and may be experienced in both

102

the peripartum and postpartum stages.

e purpose of this section is to discuss PGP management, fully realizing this condition may present in combination with LBP. Furthermore, any signs of pelvic ﬂoor dysfunction (eg, incontinence, pain with intercourse) should trigger a referral to an appropriately trained clinician.

103–105

Albert et al

identiﬁed 5 types of PRPGP, a classiﬁcation that may be useful in predicting outcomes. eir initial classiﬁcation study included 293 women experiencing pain at week 33 of gestation. e 5 types of PRPGP described are pelvic girdle syndrome, symphysiolysis, one-sided sacroiliac syndrome, double-sided sacroiliac syndrome, and miscellaneous. All patients reported that their pain occurred on a daily basis.

Pelvic girdle syndrome was deﬁned as pain in both SIJ areas as well as in the symphysis pubis. e familiar pain was reproduced with the FABER and thigh thrust (Table 5) tests. Symphysiolysis was described as pain in the symphysis pubis, conﬁrmed by reproduction of familiar pain with palpation of the symphysis pubis and reproduction of pelvic pain with the Trendelenburg

103

Despite there being no actual lysis, the term “lysis” was

test. used to be consistent with health authorities in Denmark where this research was undertaken. One-sided sacroiliac syndrome was deﬁned as pain from one SIJ conﬁrmed by thigh thrust to the symptomatic side. Double-sided sacroiliac syndrome was classiﬁed as pain in both SIJs with pain being reproduced by the thigh thrust test applied bilaterally. Miscellaneous was deﬁned

as daily pain in 1 or more pelvic joints with inconsistent ﬁndings from clinical examination.

Others have reported that the resisted hip adduction test (performed with a hand-held dynamometer at the medial aspect of the knee with patient in

106

a hook lying position being asking to squeeze the device),

107

standard lunge (Table 5),

the ASLR test,

palpation of the long dorsal SIJ ligament

107,108

109

and pain on

can also be helpful

in the examination of PRPGP.

Treatment

ere is no robust evidence to guide the clinician on which interventions should be selected for individuals with PRPGP, which may be due to the condition’s self-limiting nature.

110

Hence, interventions selected should be based on ﬁndings from the examination with the most common interventions for PRPGP centering around exercise, manual therapy, and the use of stabilization belts.

Exercise

111

Kluge et al

found a speciﬁc exercise program that decreased back pain intensity and increased functional ability for South African women with lumbar pain and PGP during pregnancy. However, a more recent systematic review

112

concluded there was limited evidence regarding the eﬀectiveness of stabilizing exercises in treating PGP during pregnancy and the postpartum period.

113

Davenport et al

conducted a recent systematic review and meta-analysis looking at exercise for the prevention and treatment of low back, pelvic girdle, and lumbopelvic pain during pregnancy. One key ﬁnding was that approximately 50% of women experience LBP or PGP during pregnancy and 25% still have pain a year later. Similar to LBP, a large portion of the pregnant population will experience PGP, and in many cases, pain resolves with time.

Unfortunately, being physically active during pregnancy

does not reduce the odds of developing pain during pregnancy or

113

post-pregnancy, for LBP. A systematic review and meta-analysis

however physical activity can be preventative

114

found that exercise alone or in combination with education was eﬀective for preventing LBP; however, no other tool such as education, stabilization belt, etc was successful by itself. e reason why exercise may prevent pain in PRPGP and LBP may be due to the ligamentous changes that occur during pregnancy, which in turn can link pain to a speciﬁc tissue laxity for PRPGP, whereas the overwhelming majority of LBP is nonspeciﬁc.

Despite limited evidence on speciﬁc exercises for either PRPGP or nonspeciﬁc PGP, the authors of this monograph have found certain exercise principles helpful to apply during treatment. Clinicians should consider factors such as patient irritability, functional limitations, and psychosocial factors when prescribing exercise. If the level of irritability is high, clinicians may choose to start in a position of comfort for the patient. However, if the patient presents with a low irritability

Academy of Orthopaedic Physical erapy, APTA.

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