Pelvic Girdle Differential Diagnosis

Jason Zafereo, PT, OCS, FAAOMPTCli i l O th di R h bilit ti Ed tiClinical Orthopedic Rehabilitation Education

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Objectives

Describe the relevant findings from the history and examination indicating the source of symptoms as:examination indicating the source of symptoms as:

– Contractile tissue – Non-contractile tissue

Nerve SIJ Hip

Describe the relevant findings from the history and examination indicating a primary impairment of:

Stiffness– Stiffness– Weakness

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CONTRACTILE TISSUE PATHOLOGY

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Subjective Exam Findings

Chief complaint: Pelvis pain Nature: Constant and

excruciating (G Min) Aggravating: Pain with

walking (G. Med and Min) uphill (G Max), Pain with firstuphill (G Max), Pain with first movements after sitting (G. Min), Pain with ipsilateral sidelying (G. Med and Min), Pain with cross-legged sittingPain with cross legged sitting (G Min/piriformis), Pain with slumped (G Med) sitting (G Max/piriformis)

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Subjective Exam Findings--Location

Gluteus minimus Gluteus medius

Travell and Simons 19925

Subjective Exam Findings--Location

Gluteus maximus Piriformis

Travell and Simons 19926

Objective Exam Findings

Test ResponseROM/Flexibility Restricted flexibility of involved muscle; ActiveROM/Flexibility Restricted flexibility of involved muscle; Active

and Passive ROM painful in opposite directions; Loss of hip flexion and horizontal adduction (All)

Muscle Provocation Testing Painful, possibly weak (no atrophy)usc e o ocat o est g a u , poss b y ea ( o at op y)Palpation 1) Focal tenderness with concordant sign

reproduction (about 3kg of pressure)2) Twitch response3) Taut band4) Often referred pain (non dermatomal) on

continued (~5sec) pressure

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NON-CONTRACTILE TISSUE PATHOLOGY

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Differential Diagnosis

The SI joint and pubic symphysissymphysis

Peripheral nerve entrapmentsp

– Lateral femoral cutaneous– Obturator

Femoral– Femoral– Sciatic

Hip non-contractile tissue

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Peripheral Nerve Entrapment

Lateral femoral cutaneous Obturatorcutaneous, Obturator, Femoral Nerves

– Entrapment under inguinal ligament (All)

– Anterior/lateral thigh pain (LFC)

– Anterior/medial thigh pain (O, F)

– Groin tenderness (All)( )– History of trauma and

surgery (All), pendulous abdomen (LFC)10

Peripheral Nerve Entrapment

Sciatic NerveE t t i t th– Entrapment against the bony sciatic notch and piriformisHi t f t– History of trauma, surgery, large wallet

– Tenderness in sciatic t h/b tt knotch/buttocks

– Posterior leg and foot pain– Gluteals should remain

strong

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Hip Non-Contractile Tissue

Joint– Groin and anterior

thigh pain Bursa Bursa

– Greater trochanter or ischium pain, may p , yextend down lateral thigh

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Subjective Exam Findings—SI Joint

Age 25-45F l

Aggravating factorsW i ht b i i itti Female

– Joint surfaces smaller, flatter, smoother

– Weight bearing via sitting, standing, gait, or stair climbingF d b di /lifti

– Longer lever arm hip to gravity line

– Hormonal

– Forward bending/lifting– Supine lying– Rolling over in bed

changes/pregnancy

History of trauma or pregnancy

– Sidelying semi-fowler with painful side up

– Sit to standpregnancy– Lifting, Loading (Fall),

Torsion13

Subjective Exam Findings- Pelvic Joint Location

SI jointU i b tt k (S1– Upper, inner buttock (S1, S2)

– Lower buttock– Posterior thigh and calf– PSIS highly correlated

with SIJ afflictions

Pubic symphysis– Local, midline to unilateral

Perineum groin abdomen– Perineum, groin, abdomen

Fortin et al 1994; Dreyfus et al 199614

SI Objective Exam Findings

Test ResponseROM Active and Passive ROM painful in same direction.

No centralization or peripheralization with repeated movements. Decreased hip ROM

Special Tests Positive SI provocation tests: Thigh thrust*, Distraction*, Compression*, Sacral thrust, Gaenslen’s; FABERs, Resisted Abduction. ASLR: 98% of severe pelvic pain patients with a positive98% of severe pelvic pain patients with a positive ASLR have the long dorsal ligament as the pain generator (Vleeming, et al. 2002)

Palpation Tenderness medial/inferior to PSIS. Long dorsalPalpation Tenderness medial/inferior to PSIS. Long dorsal ligament tenderness is common (Fortin et al 1999); Sn = .98, LR- = .02 (Vleeming et al 2002)

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SI Provocation Testing

Goal is to stress SIJ structures and provoke concordant signand provoke concordant sign

Tests may take up to 2 minutes to yield painy p

– Immediate pain consistent with hypermobility or systemic condition

– Delayed pain consistent with stiffness Sizer et al 2002; Winkel et al Sizer et al 2002; Winkel et al

1997

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SI Provocation Testing

Tests have limited validity when taken individually butwhen taken individually, but become powerful when combined

Validity– 3 or more positive tests out of 6

+LR = 4 4 3 LR = 08 19– +LR = 4-4.3, -LR = .08-.19 Laslett et al 2005; van der

Wurff et al 2006; Szadek et al 2009al 2009

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SI Provocation Testing

Combination of 3 or more tests with absencemore tests with absence of centralization

– Improved specificity from .78 to .87, sensitivity remained at .91 (+LR = 6.97)

– Currently the most valid clinical examination cluster available Laslett et al, Aust J

Physiother, 200318

SI Provocation Testing

ReliabilityThi h Th t– Thigh Thrust K = .4-.76

– Compression K = .48-.67

– Distraction K = .46-.63

– Gaenslen’s K = .58

– Sacral thrust K = .4-.6

Robinson et al 2007; Arab et al 2009;Kokmeyer et al 200219

SI Provocation Testing

Resisted AbductionSN 87 SP 1 0– SN = .87; SP = 1.0

– K = .5-.78

FABERs– SN = .10; SP = .86– K = .44-.62

Results not validated (ABD) Results not validated (ABD) Tests double as provocation

tests for hipp– Broadhurst and Bond, J Spinal

Disorders, 1998; Kokmeyer et al 200220

PRIMARY STIFFNESS IMPAIRMENT

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SI Objective Exam Findings

Objective Exam Variable ResponseObservation Externally rotated LE; Large divot posteriorObservation Externally rotated LE; Large divot posterior

to greater trochanterROM Decreased lumbosacral ipsilateral rotation

and contralateral sidebending;and contralateral sidebending; Asymmetrical loss of hip IR, specifically on side of PI (Cibulka et al 1998)

Passive accessory movement R1 occurs before P1 (Flick test)Palpation Tenderness, tightness, and presence of

positional fault(s) (Ilium/sacrum/pubis)Special Testing Positive Standing flexion, Long sit, p g g , g ,

Deerfield, Gillet, ASLRFlexibility Limited in muscles prone to hypertonicity

(piriformis)22

Reliability of Palpation/Motion Testing

ReliabilitySt di fl i

ReliabilityFlick/Spring Test– Standing flexion

K = .32-.55– Deerfield

– Flick/Spring Test K = -.06

– Gillet K = 34- 41

K = .26-.58– Supine long sit

K = .19

K .34 .41

Arab et al 2009; Bowman and Gribble 1995; O’Haire

– Palpation for position (PSIS, sacral sulcus, ILA) K = .04-.08

and Gribble 1995; O Haire and Gibbons 2000; Riddle and Freburger 2002;Robinson et al 2007

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Validity of Palpation/Motion Testing

Gillet– Sn = .43; Sp = .68Sn .43; Sp .68– Mean rotation of sacrum .2deg posterior– Mean translation .3mm

Spring testingp g g– Sn = .75; Sp = .35

Standing flexion, PSIS position, Long sit, Deerfield– 3 of 4 positive resulted in Spec 88% and Sens of 82% for3 of 4 positive resulted in Spec 88% and Sens of 82% for

identifying LS pain– Standing flexion clinically meaningful only in concert with

positive provocation testing Cibulka et al JOSPT 1999; Winkel et al 1997 Dreyfuss et al Cibulka et al, JOSPT, 1999; Winkel et al 1997 Dreyfuss et al,

Spine, 1996; Sturesson et al, Spine, 2000

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Interpretation of Testing

Standing flexionPSIS iti b t– PSIS position best evaluated at end range, not within rangeC i l PSIS i f l– Cranial PSIS on painful side indicates fixation

– Cranial PSIS on non-i f l id i di tpainful side indicates

hypermobility Winkel et al 1997

S S PSIS in sitting– Palpate inferior portion of

PSIS25

Interpretation of Testing

Supine long sit– Assist patient with

movement to avoid shifting of pelvisof pelvis

– Importance of crossover Deerfield

– Assess with shoes on and vertical compression th h h lthrough heels

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Interpretation of Cibulka Cluster Testing

Anterior innominate rotationP iti t di fl i t t– Positive standing flexion test

– PSIS high on involved side– Long sit test-leg long to shortg g g– Deerfield test-leg long to short

Posterior innominate rotation– Positive standing flexion test– PSIS low on involved side– Long sit test- leg short to longo g s t test eg s o t to o g– Deerfield test-leg short to long

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Interpretation of Testing

Gillet– Assess mobility on

nonweightbearing legPSIS should move– PSIS should move inferior with hip flexion, knee to chest

– Positive response is decreased or absent inferior PSISinferior PSIS movement

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Interpretation of Testing

ASLR– Increased pain or

difficulty with leg raise when compressionwhen compression applied indicates stiffnessN t lid t d– Not validated Lee 2004

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Flexibility Testing

Piriformis– Normal response

Hip flexion to 90degreesg

Hip adduction to 20degrees

Hip IR to 20degrees Hip IR to 20degrees

– Common substitutions Pelvic rotation Lumbar rotation

– Sahrmann 200230

Summary of Findings

Displacement– Cibulka cluster

Stiffness– Gillet– ASLR (pain

increased)increased)– Piriformis tightness– Flick test stiffness– “Butt gripper”

alignment31

PRIMARY WEAKNESS IMPAIRMENT

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Subjective Exam Findings

Subjective Exam Variable ResponseMechanism Remote history of trauma; frequent

episodes of acute attacksA ti f t S t i d i ht b i tAggravating factors Sustained weight-bearing posture;

sharp pain with sudden movementsEasing factors Manipulation; Non-weight bearing;

external supportppAssociated factors Popping, clicking, locking, catching,

during movement

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Objective Exam Findings

Objective Exam Variable ResponseActive movements Full general mobility with aberrant motion;

Greater ROM in lying than in sitting/standing

Passive physiological movement Full with decreased resistance to end range

Passive accessory movement Increased neutral zone and shearSpecial Testing Positive Gillet; Positive Active straight leg

raiseNeurological testing L5/S1 conduction loss in longstanding

instability (Lee 2004)Strength testing Weakness hip adductors

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Active Straight Leg Raise

Position: Supine with legs extendedextended

Test: Active SLR eight inches from table

Assess: Stability of pelvis and Assess: Stability of pelvis and difficulty/provocation for lifting with and without manual compressioncompression

Response: Positive test is decreased difficulty or provocation with compressionprovocation with compression

Scored on 6 point scale, with 0 = no difficulty and 5 = unable to lift35

Active Straight Leg Raise

Locations of external compressioncompression

– Applied anterior ilium Pelvic floor and TRA

– Applied posterior ilium Sacral multifidus

– Applied pubic ramus Rectus abdominus or Hip adductors

– Applied thorax to pelvis Internal/external obliques Lee 2004

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Active Straight Leg Raise

Reliability– ICC = .83

Validity– Identification of posterior pelvic

pain during and after pregnancy– Cut score set between 0 and 1– Cut score set between 0 and 1– SN = .54 - .87; SP = .88 - .94 – Diagnostic accuracy highest g y g

post-partum Mens et al, 2001 and 201237

Gillet Test

Assess mobility on i htb i lweightbearing leg

PSIS should move i t bl ithremain stable with

single limb stance Positive response is Positive response is

superior PSIS movement on stancemovement on stance side

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Strength Testing

Hip adductors– Disproportionate weakness

of adductors versus abductors associated withabductors associated with hypermobility

– May result from i it ti /di l t firritation/displacement of pubic symphysis Lee 2004 Rost et al 2004 Mens et al 200239