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Excerpt from:

The Pelvic Girdle: how does research assist best clinical practice for treatment of pelvic girdle pain and the Sacroiliac joint

Written by Barbara Hungerford PhD, APAM

 from In Touch Magazine, Australian Physiotherapy Association . Full article to be published  October 13

 

1.     ASSESSMENT AND DIAGNOSIS OF PGP AND SIJ DYSFUNCTION

The debate about how to treat the SIJ is centred on whether manual therapy, exercise rehabilitation, or a cognitive approach is most effective. Research has shown that if the sacroiliac joint is unable to move normally (fixated, stiff, compressed)²¹ this alters the information being sent from mechano receptors at the articular surface to the brain²², and this may explain the pattern of inhibition of TrA, multifidus, and ipsilateral gluteus maximus reported with SIJ dysfunction¹⁴. Physiotherapists are comfortable to treat a stiff ankle in order to improve the pattern of gliding required for forward translation of body weight with walking. Similarly, treatment of the SIJ with manual therapy is effective for acute and sub-acute presentations^23,24, especially when combined with therapeutic exercise. It is therefore essential that we understand when manual therapy is appropriate, and when progression into exercise rehabilitation is indicated.

 

Trauma to the SIJ, such as falling onto the bottom or sacrum, can alter patterns of intra-pelvic motion and sacro-iliac joint glide. Pelvic Girdle Pain (PGP) and trauma are also linked to altered lumbo-pelvic muscle activation^5,14,21,25. If the SIJ is no longer able to maintain its closed pack position with weight bearing, the SIJ will "unlock" (innominate anterior rotation/ sacral counternutation). This increases strain on the dorsal long SI ligament, creating pain in the PSIS region that is often described as worse with all weight bearing activities. Local lumbo-pelvic muscle activation is often inhibited while global muscle activation becomes more tonic. The altered lumbo-pelvic muscle activation leads to a variety of dysfunctional presentations such as buttock pain, groin pain or hamstring tension plus mal-adaptive posture and movement strategies. It should be emphasised this presentation does not indicate an unstable joint, however it does indicate functional stability is impaired.

2.     TREATMENT

The SIJ is a synovial joint that is meant to move, just not very much. Its main function is to maintain its stable closed pack alignment during all weight bearing activities to assist optimal load transfer through the pelvis and therefore treatment of SIJ dysfunction usually incorporates retraining lumbo-pelvic stability. Unfortunately sometimes an injury occurs that causes altered SIJ motion or excessive global muscle activity that compresses the SIJ. These injuries require specific manual therapy to regain normal joint glide and force closure, prior to motor control and functional lumbo-pelvic muscle retraining. Treatment of the 4 sub-groups of PGP (Table 1) can be summarised as follows:

a.    PGP due to reduced force closure: appropriate rehabilitation of local lumbo-pelvic muscles coordinated with functional retraining of global stabilisers such as the gluteal muscles and postural retraining is indicated.

b.    PGP due to excessive force closure alters functional control of lumbo-pelvic stability and increases SIJ compression. Manual therapy and re-patterning motor control to decrease the effect of overactive lumbo-pelvic muscles is required initially. Maladaptive postural habits require retraining, plus specificity in local muscle co-contraction, prior to progression into a functional lumbo-pelvic stability exercise program to improve activity.

c.     An articular injury where the joint no longer moves normally. Manual techniques are directed specifically according to whether AP or vertical arm motion is restricted. Once joint glide is restored treatment progresses to lumbo-pelvic stability, posture & functional movement retraining.

d.    An extra-articular injury to the ligamentous support network of the SIJ that causes SIJ incompetence (altered form closure). Specific retraining of timing and co-contraction of local lumbo-pelvic muscles is coordinated with functional retraining of global stabilisers into weight bearing activities. If rehabilitation fails to improve stability, and SPECT CT and passive SIJ glide tests show SIJ incompetence, prolotherapy or SIJ fusion may be indicated³³.