.. a complex longstanding SIJ/lumbar spine issue

[nari]

Here is an outline of someone I saw today who has me at a loss.

Female, 33 y.o, pleasant, non-catastrophic, sensible, good historian.
Disabling pain on (R) side of pelvis and down to the ankle,on and off for 15 years, starting with LBP during pregnancy and severe after son born. Delivery method was bizarre - forced abduction, hip flexion, ER of the (R) leg, pushing against nurse, the other leg flat. No idea why..but the torque factor and asymmetry sounds drastic. Uneventful labour.
Improved, but never went away completely.
In 2000, started playing netball, aggravated +++. Ceased.
Managed by self manipulation before trying to sleep, achieving a clunk "at the back of the hip" each time.
No neurological signs. No XRs,(!!!!) and little assistance from GP.
Went to a physio and all he did was 'core stability' on the gymball, which aggravated the pain no end, and she stopped going.
Wears a lumbar support occasionally, which helps.
Pain extends from the (R) SIJ to the groin, down femoral nerve dermatome, then switches to the postero-lateral aspect of the calf, to the malleolus. Foot is OK.
Can walk only for 10 minutes and has to stop. Sitting is worst, unable to WB on (R) side. Eased by full Abd/flexion/ER of the (R) hip, and sitting cross-legged.
Congenital absence of (L) kidney. (R) kidney function normal.

O/E: Asymmetric gait, lateral shift--> (R), poor ab control.
Difficulty in sit-->stand, shifts weight around on way up.
Compression tests positive for (R) SIJ. Both SIJs tender++
SLR--> pain in back, around L4/L5.
PKB = negative.
Prone lying induces marked contraction of erector spinae, like mountain ranges. Some mild tenderness on palpation T12-->S1, central.
Poorly tolerated, had to abandon after 5 minutes.
Supine lying tolerated. No rotation of pelvis observed in either position.
Flexion-in-lying eases. repeated FIL no change.
Neutral position of (R) leg as in normal sitting, reproduces leg pain.
Abducted position and flexed knee eases all pain.
No yellow flags obvious. Supportive mother, friends and son.

I suspect a possible spondylolisthesis, SIJ instability, thoracolumbar dysfunction and GOK what else.

My first instinct is to ask the GP for XRs at least. Patient requested them some years ago, GP refused, saying it is just sciatica.
Second instinct is SIJ dysfunction, but the referred pain pattern is weird.
Third instinct is for her to find another GP.

Any clues, guys???

This is not a complete Ax - ran out of time.

All suggestions and recommendations welcome! :roll:

It sounds rather orthopaedic and I hate orthopaedics...


Nari

[bernard]

Nari,

It sounds rather orthopaedic and I hate orthopaedics

Not sure!
What is her profession/job?
What are the muscles involved in the gait imbalance?

GOK=definition?
In my view and with your examination, she has a lot of protective reflexes and these reflexes are fortunately reversible.

[pablo]

I'm guessing GOK = God Only Knows. In which case I doubt I'll be of help.

It is surorising she has not had an X-ray. I think having some idea of what the bony structure is like can help. She may have all sorts of structural variants, and while they may not in themselves be painful, they may predispose to abnormal biomechanics and pain.

The pattern of pain is weird but is not incosistent with SIJ (and surrounding structures) referred pain. The localising signs are there, and groin pain which can be referred also. There is also a mechanism of injury or destabilising event with the pregnancy and delivery. The clunking suggests a mechanical problem. The absence of any neuro signs makes "sciatica" less likely in my mind. You mentioned SLR causes back pain, did it cause leg pain as well?

If there is a spondylolisthesis, you may be able to detect a step deformity (in prone, the spinous process of the level above the spondy will feel like it is displaced anteriorly, for L5 on S1 this means L4 will feel like it is forwards). It's worth checking.

I would also check the ASLR (active straight leg raise) test, and see wat happens with stabilisation. If the right leg causes pain and/or is subjectively heavier for the patient, and this eases with stabilisation (compression medially through the pelvis, try different levels, maybe even try diagonal forces) it may give you soemthing to go on. When performing the test, also check the breathing pattern/bracing. It's worth doing this in prone as well, noting the pattern of muscle recruitment, particularly gluts vs hamstrings.

It's probably worthwhile also checking a cluster of "SIJ" pain provocation tests: axial thrust to the thigh in 90 degrees hip flexion, Patrick's or FAbEr test, resisted hip abduction from a 30 degree abducted position. Again, they can give more information than just pain provocation.

What is her spinal position like in sitting? I have found that the chances of success are much better if a position can be found in which loading doesn't increase symptoms. This is usually a neutral spine position, and I like to start in sitting because it is easier to achieve. If you can find it, then training the patient to maintain this position and starting muscle retraining from the position before progressing is a good idea.

I'm sure Servaas would have good ideas here. He hasn't been around since his trip to Oz, I hope his enthusiasm wasn't diminished by coming Down Under!

Pablo

[nari]

Thanks guys...

Bernard, you can add GOK to the abbreviations??
She does not work at present due to her inability to sit for more than about 10 minutes and standing is not much better; a gait analysis is a good idea, but I think I need to find out more about her functioning/compensation issues in more static positions.

Pablo..

I don't think it is sciatic nerve stuff either. (R)SLR does not reproduce leg pain, only sitting in (normal) neutral does.

I was looking for a step in the Lx spine, but the hyperactive erectors prevented anything useful like that, and she was losing tolerance at this point. Might be able to pick that (or not) in a hopefully unloaded sitting position.
The FAbER test was comfortable; but I will try the SLR + different pelvic stabilisations. Problem is, she has a hard time maintaining ASLR..due to LBP. Does it matter if it is somewhat assisted? Say 30 %?

Sitting is her most painful activity, and the unloaded position with minimal pain is WB on her (L) hip and abducting/ER the (R) leg. Maybe I can sneak in some retraining just trying to increase WB on the (R) hip during (R) hip abd/ER, and try to go from there.

More later.

Thanks

Nari

[pablo]

If she has trouble doing ASLR due to pain, and the pain reduces when you apply manual compression to the pelvis, or if it becomes much easier for her to do it, it's a geen light. You then have impaired load transfer through the pelvic girdle as a definite problem, and it gives you something to work on.

Let us know more after you see her again.

Pablo

[bernard]

Hi All,

I noticed that she was a very young mother 17/18?

In my view she isn't able to make an active (pain free) pelvic tilt (but I may be wrong! :oops: ).

[nari]

What is your reasoning for this, Bernard?


Nari

[bernard]

Nari,

It is just coming from your findings =>

LBP + hyperactive erectors => inability to move freely?
Re about age: just curious, some young mothers may experience life differently?

[emad]

Hi Nari :

First of all ,why did you suspect spondylolisthesis :?:
what are the clues made you suspect spondylolisthesis :?:

Regarding your hypothesis of SIJ involvement , this hypothsis will make the issue so complex , as the SIJ is so difficult to be islolated and diagnosed , even assessed , the whole issue of pelvic refion is so complex , i belive even the literature available regarding SIJ ( at least for me ) is deficinet , as reseachers in Australia do not give that joint great attention .

i had read several articles from the Manual & Manipulative journal concerning SIJ , but no progress for me in practical applied skills , particularly these syndromes of Sacrom rotation , flexion & Extension , and they wrote a lot about SIJ play of movement assessment , but personaly , i do not belive it is actually exist .

Any way , i want to add a final point , sometimes SIJ involvement cause gluteal pain and sciatica pain , this is what i have read in one of the books .

cheers
Emad

[nari]

emad,

You are right - the jury is out on whether the SIJ moves or not, and the gurus are still arguing about it.
Lots of PTs believe the joint not to be an issue in back pain and sciatica - others do.

Why did I suspect spondylolisthesis? Extension (just prone lying) aggravated her pain, flexion eased it; walking is markedly affected. It may not be anything to do with her presentation, but something to be suspected.

Without XRs - difficult to say. I want to push for them.


Nari

[emad]

Hi Nari:

Did you evaluatd the Hip joint ? Palpation of groin region , particularly addictors , also resisted Ext Rot & Int Rot .I think it worth considered , may be there is hip joint tightness.

Well, these symptoms you mentioned usually prsentable in LBP cases , so that Spond may be suspected in all cases of low back pain because simply Spond has no cetain characters , and it woth to be considered , this issue we are discussing , because X_ray is one of the first automatic investgiations , the Physician should perform , so that The Physiotherapist Must be allowed to ask for X ray , i hope this time comes soon!!

Regarding your case , i feel it is no more than a case of SIJ dysfuction , at least because of the history of delivery.

cheers
Emad

[nari]

emad. I suspect you are right, I am seeing her later this week and will post more findings/evaluations - hopefully.


Nari

[Diane]

Nari, can you check something for me?
1. Standing, relative heights of illiac crests.
2. Lying, relative lengths of legs after bridging and lowering spine down, you take the legs out into extension.
3. If one ASIS looks "further away" from the umbilicus than the other, when you sight measure with your thumbs on ASIS's.

This info will either confirm or dispute what I think she's maybe got.
Diane

[nari]

I will try those suggestions, Diane, but given her poor tolerance of supine lying, she may not be able to complete most tests. Think I will have to move slowly....


Nari

[bernard]

Hi Nari and All,

The hip may be tested relatively easily and in seconds.
1/ lying supine => rotation of feet?, normally symmetrical and around 15/20° RE.
2/ Knee bent on the faulty side, try to do a passive but soft RE, if hip involved then resistance appears (and pain).

Spondy => knees bent to chest. Moving passively knees up and down may provoke unpleasant things. Put a towel under the lumber spine and start again. If pain reduced then spondy is a possibility.

[nari]

I saw her today again, and she was having a good day...!

She had been doing heaps of movements which did not refer pain anywhere, eg FIL.

Except for the fact that the receptionist, who rang to confirm the appointment, told her the wrong time to come - so there was a bit of seredipitious juggling.

She has been wearing the lumbar support whenever she is consistently on her feet and active; she finds it helpful.

I will try to answer all suggestions in order:

Pablo,

(R)ASLR (she was able to do this actively with much reduced pain level) + medial and diagonal compression --> increased pain in the the (R)SIJ area slightly inferior and lateral to the (R)SIJ itself. ASLR without stabilisation--> more pain.

Prone -more difficult, <normal glut recuitment and the Lx spine would not extend enough to permit the action. Pain same as above plus groin pain.

The erector spinae were much more relaxed in prone than before, and there is a distinct loss of extension of the Lx spine, with what I figured was a possible retrolisthesis of L4 on L5. Very stiff.

Axis thrust at 90 degrees hip flexion --> relief of pain.
Resisted hip abduction from 30 abd -->pain again lateral to the (R) SIJ.

Sitting was normal and comfortable, equal WB distribution.

Bernard,

pelvic tilt: fine for maximal flexion, almost zero for extension.
Rotation of hip/ankle in supine---> normal.
Leg length--> NAD
(R) knee flexion and movement was Ok with some pain, again lateral to the SIJ.
Passive flexion in lying--> no pain for flexion, pain in (R) groin (mild) on downward movement.

Diane,

Standing, iliac crest height equal (wasn't last time!)
NAD on your second test.
No apparent rotation of ASISes visually; lateral shift--> (R)=(L) and stiff for someone her age.

Gait was normal, though rather cautious (expected).
The most comfortable positions she has developed herself are:

Spaceman's - but cannot extend Lx spine.
Extreme active maximal (R) hip flexion, swinging freely from abduction (about 80 degrees abd; rather a lot!) to full adduction, in the same plane of movement - rather an awesome sight.
Crosslegged sitting with soles of feet together.
Tender++ palp of L4L5S1, SIJs but not T10-->L3.
FIS-->relief.

Still am not sure what is going on, so have requested XR of Lxspine and hip, from her GP.
I now suspect Lxspine dysfunction more than SIJ.....

All comments welcome!


Nari

[Diane]

Something I've stumbled upon that people find very comfortable and helpful, when prone ly is out of the question, is supine over bolster as a position in which to treat hips. (Same as spaceman I guess..)

Slowly growing pressure against the anterior thigh into the bolster, distracting the hip slightly, holding it when you think you've gone far enough. One hand on some tight cranky place, maybe ES or lateral cutaneous land, wait for the relaxation to emerge in the palpable tissues. After stuff relaxes, hold for two minutes or thereabouts.

Often you can be more superficial about this, and stretch out bits that are more superficial like the inguinal ligament area, by stretching skin only, and moving it more caudally, less into the femur.

In the first instance, lots of things let go, including back muscles. I think it's an applied lumbo-sacral plexus glide. It doesn't bother psoas, which is kept comfortably relaxed by the bolster, but I think it can alter the relationship for the better between psoas and the nerves that have to weave through it into the pelvis/hip/leg.

Another manoeuver in the same position is to press the trochanter gently but solidly in a medial direction. I can almost see obturator internus relaxing inside the pelvis when I do that. It's another place where deep nerves can get clenched. Again, you have to move slow and "sense" when to stop moving and just hold your pressure. It's usually when the body sighs and things relax. Can be dramatic or subtle depending on the patient.
Diane

[nari]

Update!!


I was fortunate to have another PT with me on the day the young woman returned, who had just completed a course on biomechanics/kinetics of the pelvis.
She did an assessment, and established it was the (R) SIJ, probably impacting on the lower lumbar spine. With recruitment of Trans Ab through supine, all pain disappeared with controlled TA actioning. The explanation of why the patient found the most comfortable position was extreme flex/abd/ER of the (R) hip and swinging the (R) leg into SLR, was inexplicable, because it reproduced, more or less, the very position in labour that caused the problem 14 years ago. It also compresses the SIJ.

So there are gaps, but the patient can now control the pain better, and was very pleased she could administer her own 'analgesic' effect. Being vertical is still a problem, but I am hoping that will change.

Diane, thanks for your ideas; I will try them once I feel she is OK with her TA control. Interestingly, when she came on the day the other PT was with me, she was quite relaxed and comfortable in prone - for the first time. So between the two of us - who knows what will be achieved..

I still suspect the Lxspine - because all the features of SIJ dysfunction are not as consistent as indications for Lxspine are. but that is probably my bias showing; I do not know much at all about SIJs.


Nari

The odd thing

[ginger]

to nari and others, I have read your thoughts and observations on the woman in question and wanted to offer the following assessment method and other ideas . It does appear from your evidence that she probably has an immobile SIJ. The effect of this will be to create abnormal biomechanical forces that lead to the stiffness you mentioned. You made a point of observing stiffness at L4, much of her referred pain is in this dermatome. Some of it however would be explained by a corrollory to L4 problems . Piriformis "syndrome" or an irritation to the sciatic trunk at the junction of pelvis and thigh where this nerve exits the pelvis. Tightness of piriformis here caused by activation by L4 irritation, will cause pain in the distribution mentioned. This is often made worse by both sitting and standing for extended periods. To test A. the SIJ,
Have patient stand facing away from you , therapist seated. Place thumbs at both psis's, observe the rearward rotation ( or lack thereof ) of the ipsilateral psis when that hip knee is flexed to 90degrees. A stiff SIJ will fail to rotate rearward and instead hitch upwards , or remain horizontal. A fully functional SIJ should be felt and seen to rotate about 8 degrees rearward., If you are unsure how to proceed with SIJ mobilising , let me know and I will post more detailed info re this method.
B.Piriformis is palpated with patient in side lying , the painfull side up, Her hip and knee in 90 plus flexion with some adduction of hip also. Palpate deep to the midpoint between Ischium and greater trochanter, through Gluteals. Extreme tenderness palpable there will not induce her referred pain but deep massage and Ultrasound will quickly reduce the muscular tightness .Pain reduction will quickly follow.
C. having mentioned Lumbar tightness, this must be addressed with unilateral mobilisation treatments , particularly to L2 and L4 ( some of her groin pain may be directly referred by the upper lumbar joints.)
If you need further info on these treatments and assessments I would be glad to offer more. e-mail me at fishergn@hotmail.com
All the best.

[nari]

ginger
Thank you for your thoughtful reply and further offers of help.

I am not sure that her anterior thigh pain is a result of dysfunction at L4. It is too erratically produced.
I am familiar with all the procedures you mentioned, but I do believe the SIJ is too mobile, rather than hypomobile or immobile. She does not hitch on testing the psis's, but rotates. At least that is how I observe it.
I have considered mobilising the L2/L4 segments and then aim to preserve any 'release' that occurs with practising control of rotation in dynamic posturing.

If you feel her bizarre actions for pain relief (extreme abd, flexion and ER of the ipsilateral hip) and then swinging it in full SLR to the other side in full adduction is due to an immobile SIJ - can you explain further?

Will let you know further of developments!


Nari

[ginger]

My curiosity was aroused by you having mentioned the SIJ in your assessment, I don't believe her pain is due to discrete pain of the SIJ. In fact I can count back at least ten years since I have observed actual SIJ pain that could not be explained by referred pain from L1/2 or confusion with L5 pain radiating into the sacral area. As you have mentioned lumbar stiffness , her pain is much more likely to be fully explained , by referred pain from the spine, with of course her anterior thigh pain coming from L3.
Sounds like piriformis involvement just the same as well , which may explain her odd antalgic behaviour ( that or shes warming up to kick the footie). Good luck and talk some more when you can.

[Diane]

I agree with Ginger, and T12 can be a player too. Not referred pain from the "joints", but from the cutaneous distribution over the posterior pelvis that orgininates at those levels.. check this out:
http://education.yahoo.com/reference/gray/subjects/subject?id=209

Go down to the picture of skin, and click on "enlarge". Skin stretching works well for clearing pain from these nerves. They must mobilize somehow through skin stretching.

Cheers,
Diane

PS: Actually the whole neuro section is worth checking out. I love just staring at the patterns of the visuals. There is a diagram depicting an accessory obturator nerve! Something to bear in mind with people who have bewildering groin or anterior hip pain..

[bernard]

Ditto Diane =>

http://www.somasimple.com/images/gray/802.gif