Sacroiliac joint and

pelvis complex
Medical background, Examination, Evaluation, Diagnosis,
Differential Diagnosis, Plan of Care, and Intervention
 Sacroiliac joint
SYNDROME
• It is often caused by disruption to the
ligaments of the SI joint.
• It is more common in active men, pregnant
women, and the elderly.
• When the SI ligaments are torn or damaged,
it causes inflammation of the joint and
disruption, causing pain
• Trauma is the most common cause.
Degeneration needs to be considered as well
 CLINICAL Presentation
• Often described as pain over the posterior aspect of the joint.
• Pain on the low back, buttock, and thigh are common
• Sitting in one place for too long is difficult
• Tenderness of the joint is also present
• Pain occurs when the joint is mechanically stressed such as
during forward bending
 Examination
• Palpation, stress tests, and movement examination all help
to identify the possibility of SI joint dysfunction, or to rule out
• Test item cluster for the SI joint:
• Distraction test Standing Flexion test
• Compression test Seated flexion test
• Thigh thrust test
• Sacral thrust test
• Gaenslen’s test
• Diagnostic nerve block: An anesthetic is inserted into the SI
joint. It is the gold standard for diagnosing SI pathologies
 Intervention
• Acute phase: utilize the principles of PRICEMEM.
• Following the initial phase, techniques such as
mobilizations and manipulation may help improve the
mobility of the joint.
• If there are complaints of instability:
• use a sacroiliac belt to temporarily support the pelvis
• perform a progressive stabilization training
• Postural and ergonomic advice will help the patient to
decrease the risk of reinjury.
 Osteitis pubis
• an activity-related lower abdominal and
proximal adductor pain in athletes.
• common during the third and fourth
decades of life, especially in men.
• overuse is the most likely etiology of the
inflammation, and the process is usually
self-limiting.
• MOI: activities that create shearing forces
at the pubic symphysis
 Classification

Stage Characteristics
I Pain located in the unilateral kicking leg and a pain level that
worsens after training

II Bilateral inguinal pain and a pain level that worsens after training
III Bilateral inguinal and lower abdominal muscle pain, and a pain level
that worsens with kicking, sprinting, changing direction, long walks
and transitioning from sit to stand

IV Bilateral inguinal, lower abdominal, and low back pain, and a pain
level that worsens with defecation, sneezing, walking, and prevents
the individual from performing ADLs
 Clinical presentation
• Gradually increasing lower abdominal and proximal adductor pain
• Symptoms been described as groin burning, with discomfort while climbing
stairs, coughing, or sneezing
• Discomfort while climbing stairs, coughing, or sneezing
• LOM in one or both hips
• An adductor spasm might occur with limited abduction
• an audible or palpable click over the symphysis
• A soft tissue mass with calcification may also be detected
 Examination
• Evaluation of the hip joint to rule out an intra or extraarticular hip pathology is
necessary
• Pain can be elicited by having the patient squeeze a fist between the knees
with resisted adductor contraction in flexion and extension.
• Pubic motion is assessed by locating the pubic crest and then gently testing the
mobility of each available direction
• A resisted sit-up with palpation of the inferolateral distal rectus abdominis may
recreate symptoms
• Valsalva maneuvers can occasionally reproduce symptoms
• Plain film imaging may reveal degenerative changes
(subchondral cysts or osteophytes)
 Intervention
Phase I
• Static adduction
• Abdominal sit-ups
• Abdominal crunches
• Balance training
• One-foot exercises on the
sliding board
Phase II (from the third week)
• Side-lying abduction and
adduction
• Lumbar extension in prone
• One leg weight pulling
abduction and adduction
• Abdominal sit-ups
• One-leg coordination
• Skating movements on a
sliding board
Peripartum Posterior Pelvic Pain
• An unexplained pain in the pelvic region
during or after pregnancy
• Almost half of all pregnant women
experience this problem
• linked to the physiological adaptations that
occur in preparation for childbirth
 Clinical presentation
• Pain in the SI joint or lumbar region
• Worsen with muscle fatigue from static postures, or as the
day progresses
• Relieved with rest or change of position
• There maybe associated pelvic floor weakness
• Increased lumbar lordosis and increased thoracic kyphosis
• forward head and rounded shoulders
 Examination
• The strength of the pelvic floor muscles and the abdominals
are examined since these weaken during pregnancy.
• Posture and gait dysfunctions are also examined especially
with the anterosuperior shift of the COG
• Balance is also examined, and it is again related to the
shifting of the COG
• The rib cage circumference is measured since this should
increase in pregnant women due to the increased oxygen
demands
 Intervention
• The symptoms can be treated effectively with many traditional
low back exercises, pbm, posture instructions, improvement in
work techniques, and superficial modality application.
• There are specific exercises to improve abdominal strength,
pelvic mechanics, and pelvic floor strength in the pregnant
women.
• Interventions include neuromuscular reeducation, patient
education, biofeedback with instrumentation, and motor control
exercises
• Proper breathing and relaxation techniques are also taught to
the patient
 Diastasis Recti: OVERVIEW
• Separation of the rectus abdominis in the midline at the
linea alba.
• it is common in pre and postpartum women
• It may occur in pregnancy as a result of hormonal
effects on the connective tissue and the biomechanical
changes of pregnancy.
• Clinical presentation:
 A gap in the midline of the abdomen may be felt with
accompanying weakness of the trunk flexors.
 Difficulty in independent supine-to-sitting transitions.
 Severe cases may progress to herniation of the
abdominal viscera
 Examination
• To identify diastasis recti, the clinician palpates at the
abdominal area and check for any palpable gap indicative of
separation.
• On postpartum day 3, the abdominals should be evaluated for
diastasis recti.
• Examination of abdominal muscle strength is also necessary
since these muscles are the ones affected.
 Intervention

• Corrective exercises for diastasis recti are prescribed until the

separation is decreased to 2 cm or less before resuming more
strenuous abdominal strengthening
• If exercise has not been started before or during pregnancy,
basic abdominal isometrics with exhalation should begin within
24 hours of delivery.
• The patient should be instructed to self-monitor the diastasis recti
• The patient should also be instructed to avoid unsafe postures
and exercises such as bilateral SLR, fire hydrant exercises,
quadruped hip extension, and unilateral weight-bearing activities
Symphysis Pubic Dysfunction
• occurs when the ligaments between the
pubic symphysis ARe stretched and allow
the bones to move to each other.
• commonly occurs during pregnancy and
should always be considered when
examining patients in the postpartum period.
• ligamentous laxity during pregnancy is the
usual cause.
• Pelvic misalignment in the non-pregnant
population may also be the cause.
 Clinical presentation
• suprapubic, SI, or thigh pain
• pain with any activity that involves lifting one leg at a time or
parting the legs.
• An antalgic, waddling gait.
• pain can be evoked by bilateral pressure on the trochanters
or by hip flexion with the legs extended.
• tenderness at the anterior pubic symphysis.
 Classification

Stage Characteristics

I Minor anterior damage, mild pubic symphysis diastasis, and

(vertical) pubic rami fracture

II Wide diastasis of the symphysis pubis, disruption of the anterior SI

ligament complex, and hinging of the iliac bone on the sacrum at
the intact posterior SI joint

III Total disruption of the SIJ and wide diastasis of the symphysis
pubis
 Examination
• The subjective examination will help the clinician identify the
quality and location of pain
• The objective examination includes posture and gait analysis,
palpation, and ROM examination
• SI joint stress tests may also be positive
• The radiological evaluation may occasionally be useful in
confirming the diagnosis
 Intervention
• Conservative intervention involves bed rest, pelvic, ambulation
with an assistive device and a graded exercise progression
• Swimming, except for the breaststroke, and deep-water
aerobics using floatation devices may help relieve pressure on
the joint.
• In severe cases, surgical intervention may be utilized in cases
of inadequate reduction, recurrent diastasis, or persistent
symptoms
Coccydynia
• A painful and potentially debilitating
condition of the coccyx. It is a symptom,
not a disease
• Women and individuals with an
increased body mass index are more
likely to have symptoms consistent with
coccydynia.
• tends to occur when the coccyx
becomes stuck into flexion with an
accompanying deviation.
 Classification
1. Idiopathic: Unidentifiable cause or origin
2. Posttraumatic: May be due to a fall onto the buttocks, or
due to difficult childbirth
 Clinical presentation
• Associated with posterior sacrococcygeal subluxation
• pain in the coccyx region during, going into, or coming out of a
seated position
• Tenderness over the coccyx
• Pain worsens during sit to stand and bowel movement.
• pain can be relieved by sitting on a hard surface or with the
buttocks over the border of the chair.
 Examination
• There is no imaging gold standard for the diagnosis of
coccydynia
• Most of the time, physical examination will suffice in diagnosing
it
• Given the intrarectal nature of this examination, the procedure
must be carefully explained to the patient, and verbal consent is
obtained before performing the examination
• The clinician assesses the degree of movement in the AP
direction.
• Palpation may help to discern between different forms of
coccygodynia.
 Intervention
• The goal is to controlling pain by pressure relief and activity
modification
• Inflammation control is through the principles of PRICEMEM
• A typical intervention includes NSAIDs, manual therapy, and
local cortisone injections
• If the mobility is felt to be restricted, the coccyx can either be
distracted or mobilized
• Patients are educated on activity and ergonomic modifications
such as padding the chairs, pressure relief techniques, and
avoiding prolonged sitting and standing.
OTHER CONDITIONS
• Acute appendicitis: INFLAMMATION OF THE APPENDIX. It begins with a
dull, aching pain in the right lower abdomen, which worsens by walking,
coughing, and moving the trunk. The pain is often localized at the
McBurney point.
• Iliopsoas hematoma: A collection of blood AT THE ILIOPSOAS due to
localized bleeding. Patients initially complain of pain in the side of the trunk
between the upper abdomen and the flank and develop motor and sensory
deficits along the femoral nerve distribution. A mass may be palpated in
the lower abdomen. Conservative intervention involves bed rest, followed
by gentle hip AROME and progressive strengthening.
OTHER CONDITIONS
• Iliopsoas abscess: The pain occurs in the right lower abdomen
and worsens with hip extension and palpation in the right iliac
fossa. It is caused by an infection of the thoracolumbar spine or
is secondary to an intestinal disorder.
• Sign of the buttock: a collection of signs indicating a severe
pathology posterior to the axis of sagittal motions in the hip.
There is a non-capsular pattern of LOM, hip extension is painful
and weak, and there is gluteal swelling. Hip flexion is also
limited and has an empty end-feel.
OTHER CONDITIONS
• Groin pain: Chronic pain in the groin region is difficult to
evaluate, and the cause is poorly understood. It is often
associated with a variety of conditions.
• Meralgia paresthetica (Bernhardt-Roth syndrome): It is a
syndrome of pain caused by entrapment of the lateral femoral
cutaneous nerve. This syndrome causes pain, dysesthesias,
and numbness along the anterolateral thigh. Walking, standing,
and prone positions worsen the pain while sitting may help to
relieve it. Intervention is dependent on the cause.
GYNECOLOGIC CONDITIONS
• Pelvic inflammatory disease (PID): It is the general term describing
endometritis, salpingitis, tuboovarian abscess, or pelvic peritonitis. It is
assumed to occur by the ascending spread of microorganisms from the
vagina or endocervix into the upper genital tract. The characteristic
presentation is suprapubic pain with fever, vaginal discharge, chills, and
direct abdominal tenderness.
• Tubal pregnancy: In its early stages, this condition usually produces mild
and colicky lower abdominal pain. The pain is caused by an ectopic
pregnancy. It is usually associated with abnormal menstruation and
irregular spotting or staining.
GYNECOLOGIC CONDITIONS
• Endometriosis: a common gynecologic disorder that can be found
anywhere in the pelvis. It is linked to abdominal, midline, and pelvic pain. it
has common characteristics with malignant cells. It is linked to abdominal,
midline, and pelvic pain.
• Interstitial cystitis: a clinical syndrome of urinary frequency, pelvic pain, or
both, in a patient in whom no other pathology can be established. The pain
can occur in locations throughout the pelvis, including the urethra, vagina,
suprapubic area, lower abdomen and back, medial thigh, and inguinal
area.
• Uterine prolapse: the collapse or downward displacement of the uterus
and occurs most often after childbirth. Symptoms include a bulge in the
vaginal opening, pelvic pressure, perineal heaviness, and backache.
RHEUMATIC CONDITIONS
• Ankylosing spondylitis: A chronic rheumatoid disorder that is usually
progressive, resulting in a full ankylosing of the SI joints. It is a form of
spondyloarthropathy. Tests to discriminate SIJ tenderness caused by
ankylosing spondylitis from that caused by mechanical spine conditions
include passive hip extension, AP pressure to the sacrum, and the primary
stress tests.
• Sacroiliac arthritis: characterized by pain in the posterior sacrum or groin,
which can radiate into the posterior thigh. Lumbar extension is the most
painful motion, and flexion is the least. It may be present if the pain
worsens with unilateral weight-bearing or hopping but is reduced if a
sacroiliac belt is worn.
ONCOLOGIC CONDITIONS
• Ovarian cancer: the second most common reproductive cancer in women
and the leading cause of death from gynecologic malignancies. Its
incidence Is between 40 and 70 years. Identification of the BRCA1 or
BRCA2 genetic mutation may offer the possibility of identifying women at
risk for this disease. Pelvic or abdominal discomfort, bloating, increase in
abdominal or waist size, vaginal bleeding, and indigestion are all
symptoms.
• Prostate cancer: It is the most common non-skin cancer and the most
common cancer in males. It is often diagnosed serendipitously because of
urinary obstruction or sciatica. Serum PSA is the most useful tool for the
early detection of prostate cancer.
ONCOLOGIC CONDITIONS
• Endometrial (Uterine) cancer: It is a cancer of the uterine endometrium. It
is the most common gynecologic cancer, usually occurring in
postmenopausal women between the 50 and 70 years. The most common
symptom is abnormal vaginal bleeding or discharge and pelvic pain.
• Cervical cancer: It is the most common cause of death from gynecologic
cancer in the world. Since the widespread introduction of the Papanicolaou
(Pap) smear as a standard screening tool, the diagnosis of cervical cancer
at the invasive stage has decreased. Clinical symptoms related to the
advanced disease include painful intercourse; postcoital, coital, or
intermenstrual bleeding; and a watery, foul-smelling vaginal discharge.