Torn Glute?

[alophysio]

THanks for the reply Karen.

1. Overt trauma is not necessary for disc injury to occur. This is because of lots of microfractures to the annulus can add up to the disc reaching the outer 1/3 of the annulus which is innervated. Lucas is a yoga student/teacher - he will no doubt do LOTS of F + Rot enough to strain the discs - they take most of the segmental rotational loading in the L/S.

2. SIJ pain rarely refers into the hip joint. This has been confirmed by Fortin et al and widely accepted (1994 Spine 19(13): 1475-1489 - 2 part articles)

STUDY DESIGN. Pain pattern mapping of the sacroiliac joint in asymptomatic volunteers was investigated. Prospective evaluation of 10 volunteers who received sacroiliac joint injections was performed. The injections consisted of contrast material followed by Xylocaine. OBJECTIVES. To determine the pain referral pattern of the sacroiliac joint in asymptomatic individuals. SUMMARY OF BACKGROUND DATA. All 10 individuals experienced discomfort upon initial injection, with the most significant sensation felt directly around the injection site. Subsequent sensory examination revealed an area of hypesthesia running caudally from the posterior superior iliac spine. METHODS. Volunteers were asked to describe the nature and location of the sensation upon sacroiliac injection. Sensory examination immediately followed the injection to determine referral patterns. RESULTS. Sensory examination immediately after sacroiliac injection revealed an area of buttock hypesthesia extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine. This area of hypesthesia corresponded to the area of maximal pain noted upon injection. CONCLUSION. A pain referral map was successfully generated using provocative injections into the right sacroiliac joint in asymptomatic volunteers.

Having said that, certainly a dysfunction of the SIJ can lead to hip joint problems but SIJ pain itself does not refer to the hip - the L/S does.

If you are seeing patients with hip pain, no positive hip signs but positive SIJ signs, then perhaps a L/S dysfunction is driving the SIJ dysfunction...Load transfer problems will also cause hip issues but you will find muscular or hip joint associations with this... to find NO hip signs and ONLY SIJ signs would be rare i would think...

3. I agree with the SIJ causing hip mm spasm also mimicking sciatica but it has to fit with the rest of the picture as described above... Your tight piriformis and gluts will show up on a hip screen (positive hip signs right?)

4. Posterior pelvic tilt may or may not stress the SIJ. If the SIJ is dysfunctional then they will counternutate and stress the Long Dorsal Lig which would then be sore on palpation (which incidently is over the Fortin area of pain...). If the SIJ is NOT dysfunctional, then it should merely stay in nutation (close packed position) and transfer the load as a good SIJ team should...

5. If the SIJ is truly stressed, then the pain should not centralise with a L/S McKenzie Evaluation yet be positive with Laslett's 5 tests of SIJ pain provocation (2003 AJP Vol 49: 89-97).

Research suggests that clinical examination of the lumbar spine and pelvis is unable to predict the results of diagnostic injections used as reference standards. The purpose of this study was to assess the diagnostic accuracy of a clinical examination in identifying symptomatic and asymptomatic sacroiliac joints using double diagnostic injections as the reference standard. In a blinded concurrent criterion-related validity design study, 48 patients with chronic lumbopelvic pain referred for diagnostic spinal injection procedures were examined using a specific clinical examination and received diagnostic intraarticular sacroiliac joint injections. The centralisation and peripheralisation phenomena were used to identify possible discogenic pain and the results from provocation sacroiliac joint tests were used as part of the clinical reasoning process. Eleven patients had sacroiliac joint pain confirmed by double diagnostic injection. Ten of the 11 sacroiliac joint patients met clinical examination criteria for having sacroiliac joint pain. In the primary subset analysis of 34 patients, sensitivity, specificity and positive likelihood ratio (95% confidence intervals) of the clinical evaluation were 91% (62 to 98), 83% (68 to 96) and 6.97(2.70 to 20.27) respectively. The diagnostic accuracy of the clinical examination and clinical reasoning process was superior to the sacroiliac joint pain provocation tests alone. A specific clinical examination and reasoning process can differentiate between symptomatic and asymptomatic sacroiliac joints

His tests were...
a. Distraction of the anterior SIJ (or compression of the posterior SIJ)
b. THigh Thrust in 90 hip F
c. Gaenslens Test - like Thomas test except over the edge of the bed to stabilise the Sacrum on the bed and then posteriorly rotate the innominate with hip F
d. Compression of the anterior SIJ in sidelying (on distraction of the posterior SIJ)
e. Sacral thrust (prone, PA pressure over sacrum).

His study in 2003 showed that if the L/S Mackenzie eval DID NOT centralise OR peripheralise the pain but the patients had 3/5 SIJ Pain provocation tests positive then they were 83% likely to have a painful SIJ (specificity = SPIN = specific positive test rules it IN, SNOUT = sensitive negative test rules it OUT which was 91% - that is if negative then 91% likely to be negative)

6. If the SIJ is painful then it would be painful on load transfer tests - Active Straight Leg Raise, Stork test in stance phase, etc. You would imagine that one leg standing would be more painful than 2 leg standing if the SIJ was painful.

It is for these reasons that i don't think the SIJ is the pain producing structure nor the primary dysfunction.

However, i am more than happy to be wrong and i appreciate any discussion about these things - it is the best way for me to learn!

THanks again Karen