SIJ/Ligament sensitivty?

[block]

Hi

Its my first post here so hello! and i'll thank you all in advance for your responses.

Ok -I have a patient (slim, female mid 20's - desk/pc work) with pain situated over right PSIS who experiences pain into buttocks and quite freq into back of leg and calf (sometimes just calf)

They've had it for 2 months cant sit on righte side (sits tilted with right buttock off chair)
Patient stands with pelvis sifted over to the right and forwards. Right Side flex is painful but not restricted (unless they extend at same time) Left side flex is fine but the movement looks awful as in theres a significant left side-glide shift before flexing to left.
Extension is limited and inconsistently painful - Flex is approx 1/4 range and very painful requiring hands on leg and with a general shift of the torso to the right this time.

Supine and prone is painful if too long and patient (in supine) exp pain before 1/2 range of both posterior and anterior pelvic tilt.

Lying lumbar rotation (crook lying) also causes pain when legs go to right - when right leg rotates to right pain comes on quite soon

Palpation - Thspx and Lumbar stiff but right lumbar transverse feel rotated to right with hypertonicity in erectors

I prescibed Mackenzie type lateral pelvic shifts to left - taught TrAb and also got pt to tilt pelvic horizontally in supine (crook lying)

I intend to treat this by attending to neural prob with Mackenzie approach and the instability through general core as pain permits - especially hip stability.

Would you all kind of agree with this?

Reason being a very well respected specialise viewed part of my Ax and didn't think there was a discogenic contribution and more confusingly mentioned I should pay more consideration to the structure which represeted the exact location of the pain on palpation - which I noted was over almost exactly over the PSIS - now apart from part of iliocostalis lumboroum the only other thing it'd be

I know of is the long dorsal sacroilliac ligament which was very tight (so was left side though) when the SIJ was given PA pressure - discomfort at first which subsided quickly - both sides equall in terms of movement.

Im not sure what significance this 'advice' by the other physio means to be honest - I will admit i was kind of preoccupied with the overwhelming 'wobbliness' of the patients lumbar/pelvic but the more I think about it the more confused I get!

Please Help Me!!!
as they moved -

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[sandy_sana]

hai this is my first response ,so i am just giving my opinion ,as you hav told that cust is having a problem with PSIS ,just check with her regular sitting posture becuase software people are not bothered about their posture ,so she must hav strained a sciatica ,due to which she is having pain in her leg,and calf ,so the solution would be try giving mild manual traction ,make the patient lie in supine position bend (very slowly)both the knees to 90 degrees and keep 3 pillows under the knees .
you must gradually increase the height to 90 because patient will hav severe pain ,so increase the height to 70 leave in the same position for 10 min then increase the range for 10 degrees leave it for 10 min ,GRADUALLY INCREASE THE HEIGHT ,so keep repeating this position per day for 5 min then for 10 min and slowly increase the time ,but when patients comes to normal supine lyeing from crook lyeing may hav severe pain so hav to wait in the same posture for some time ,then correct the standing posture by giving mental confidence ,she may improve ,but PSYCHOLOGY PART IS VERY IMPORTANT HERE .
I hav tried it ,has given me good result , you may also try .

[jesspt]

You might want to try to use Treatment Based Classification system as developed by Anthony Delitto and others at the University of Pittsburgh. Here's an article you could look up which may be helpful to you:

Subgrouping patients with low back pain: evolution of a classification approach to physical therapy
J Orthop Sports Phys Ther. 2007 Jun;37(6):290-302

Based on the info you provided, I cna't see that you performed adequate testing to either rule in or rule out the lumbar spine. Until you do that, I don't think you can impliate the SIJ. When/if the lumbar spine is clear, I'd focus on pain provocation tests for the SIJ rather than any palpatory/alignment tests.

[block]

Thanks for the ref - im gonna have a look at it now. Im convinced it is the Lumbar spine, so im not looking to clear it! (sorry if my post was misleading) my questions more to do with the difficulty in understanding what my fellow physio was hinting at
(I cant ask as they only 'visit' occasionally) they basically said that the long dorsal scroilliac ligament had some kind of significance but I couldn't see it personally -just wondered if anyone else did?

[Yarok]

hi

looks like jammed L/S, mobs/man should help eventually can add neuromobs.

all the best

[schischka]

Hi there....

I don't think you mentioned any mechanism to injury, but from what you describe I still think it could very well be discogenic. However if your patient was quite acute on this assessment it's obviously harder to get a better clinical picture.

The point that you mention pain/discomfort on sitting thru R buttock could also be tight piriformis (usually spasms with back/pelvis pain anyway), this would of course impinge on the sciatic nerve, most likely explaining her leg symptoms. It might also just be compressing thru their R side aggravating the lesion

I would agree with your Mackenzie approach, however I'd also be adding prone extensions, and if symptoms centralize or reduce then you know treatment is successful. If patient generated lateral shift corrections are not successful (if you believe there is a significant shift), you may need to get stuck in yourself.

If it is disk and it does reduce and becomes more stable, then mobs may be needed to free-up that secondary stiffness. However manips to me seem to be much more effective and instantaneous in relieving joint pain

Other than this, yes! core exercises, plus reducing any sore spasmed muscles (piriformis, paraspinals, quadratus lumborum, gluts etc)

[linbin]

hi friend i agree with the previous post.it sounds like discogenic +piriformis involvement .check out tests for piriformis syndrome.

[jesspt]

it's been my experience that true piriformis syndrome is rare.

The suggestions below are all fine, but if you combine them, you're throwing everything but the kitchen sink at the patient. I'd recommed you attempt to find which treatment group (i.e. specific, directional exercise such a McKenzie; lumbar manipulation, lumbar stabilization or possible traction). Then, make one treatment type the focus of subsequent sessions. If you throw all of these treatment variables at the patient, all at once, you really make the picture far more muddy than it needs to be.

First question: Did you do a formal McKenzie repeated movements exam at initial exam?