SCREENING THE SACRUM, SACROILIAC, AND PELVIS

• Physical therapists must be able to identify signs and symptoms of

systemic origin that can mimic Neuro-musculoskeletal dysfunction.
SACRUM AND SACROILIAC JOINT
• No single physical examination finding can predict a disorder of the SI
joint.
• Pain originating from the SI joint can mimic pain referred from lumbar
disc herniation, spinal stenosis, facet joint dysfunction, or even a
disorder of the hip.
Important Physical event related to sacral Injury:

• Misstep of curb
• Fall on hip or buttock
• Lifting of object in twisted position
• Childbirth
• SI pain aggravates on sitting and lying on involved side
SACRUM AND SACROILIAC JOINT

• Typical systemic diseases that refer pain to the sacrum and sacroiliac
joint: gynaecological, prostate cancer.
• Red Flags : Sacroiliac/sacral pain without a history of trauma , H/O of
cancer, ulcerative colitis, Crohn's disease, irritable bowel syndrome.
SACRUM AND SACROILIAC JOINT

• Risk Factors : Osteoporosis, Sexually transmitted infection, Long-term

use of antibiotics (colitis)
• Clinical Presentation : Lack of objective findings, Anterior pelvic,
suprapubic, or low abdominal pain at the same level as the sacrum
INFECTIOUS/INFLAMMATORY CAUSES

• Infection is unilateral and is caused by Pseudomonas aeruginosa,

Staphylococcus aureus, Cryptococcus organisms or Mycobacterium
tuberculosis.
• Inflammation of the sacroiliac joint may result from trauma.
• Sacroiliitis is present in all individuals with ankylosing spondylitis.
RHEUMATIC DISEASESAS A CAUSE OF SACRAL OR SI
PAIN

• Common systemic causes of sacral pain are non-infected,

inflammatory erosive rheumatic diseases that target the SI, including
ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, and
arthritis associated with inflammatory bowel disease.
SPONDYLOGENIC CAUSES OF SACRAL/SACROILIAC PAIN

• Metabolic bone disease (MBD)

• osteoporosis,
• Paget's disease,
• Osteodystrophy
• Can result in loss of bone mineral density and deformity or fracture of
the sacrum.
Unilateral sacroiliac (SI) pain
pattern
Pain coming from the sacroiliac joint
is usually centered over the area of
the posterior superior iliac spine
(PSIS), with tenderness directly over
the PSIS. Lower lumbar pain occurs in
72% of cases; it rarely presents as
upper lumbar pain above L5 (6%). It
may radiate over the buttocks (94%),
down the posterior–lateral thigh
(50%), and even past the knee to the
ankle (14%) and lateral foot (8%).
Paresthesias in the leg are not a
typical feature of SI joint pain.
• A patient presented with complaint of lower back pain, history of fall,
no radiating pain, he is unable to sit on chair…..

• ???
Coccygodynia
• Mostly result of trauma such as a fall directly on the tailbone
or events associated with childbirth.
• Symptoms include localized pain in the tailbone that is
usually aggravated by:
• Direct pressure such as that caused by sitting
• Passing gas
• Having a bowel movement
• Persistent coccygodynia with a history of trauma, the therapist must
keep in mind the possibility of rectal or bladder lesions
Ankylosing Spondylitis
Ankylosing spondylitis is a type of arthritis that causes inflammation
in the joints and ligaments of the spine.
• Chronic , Autoimmune
• 20-40 year , Male commonly (3:1)
• Pain better with activity
• Chest expansion less
• Morning stiffness
• Fatigue
• HLA B27
• Bamboo spine
• RA factor
• Reiter disease (Arthritis , Conjunctivitis & Urethritis)
Sciatica

• Pain along the sciatic nerve from the spine to the foot.
• Numbness in the groin, rectum, leg, calf, foot, or toes
• Diminished/ absent deep tendon reflexes
• Weakness in L4, L5, S I , S2 myotomes
• Constant burning or sharp pain.
• Foot drop with gait disturbance
• Imaging and laboratory studies, the clinical picture of sciatica is
essential to distinguish from conditions such as neoplasm and
infection.
• ESR, and abnormal imaging are effective tools in screening for
neoplasm and other systemic disease.
• Imaging studies are an essential part of the medical diagnosis.
Pelvic Congestion Syndrome
Varicose veins of the ovaries (varicosities) cause the blood in the veins
to flow downward rather than up toward the heart. They are a
manifestation of PVD and a potential cause of chronic pelvic pain. The
condition has been called pelvic congestion syndrome (PCS) or ovarian
varicocele.
Ovarian venous reflux and stasis produce venous dilatation, congestion,
and pelvic pain. Any compromise of the valves (or blood vessels) in the
area can lead to this condition.
It can also occur as the result of kidney removal or donation because
the ovarian vein is cut when the kidney is removed.
Ovarian varicosities associated
with pelvic congestion syndrome
are the cause of chronic pelvic pain
for women. This form of venous
insufficiency is often accompanied
by prominent varicose veins
elsewhere in the lower quadrant
(buttocks, thighs, calves). Men may
have similar varicosities of the
scrotum.
• Tenderness on deep palpation of
the ovarian point (located on the
imaginary line drawn from the
anterior superior iliac spine
(ASIS) to the umbilicus where
the upper one-third meets the
lower two-thirds).
 Key Points to Remember
• Pelvic pain that is made worse after 5 to 10 minutes of physical
activity or exertion but goes away with rest or cessation of the activity
describes: Vascular pattern of ischemia
• Pain that is relieved by placing a pillow or support under the hips and
buttocks describes: Response to vascular congestion
• A positive Blumberg’s sign indicates: Pelvic infection
• McBurney’s point for appendicitis is located: Approximately one-half
the distance from the ASIS toward the umbilicus, usually on the right
side
Cancer as a cause of sacral or pelvic pain is usually characterized by:
• A previous history of reproductive cancer
• Constant pain
• Blood in the urine or stools
• Constitutional symptoms
Reproduced or increased abdominal or pelvic pain when the iliopsoas
muscle test is performed suggests inflammation or abscess of the
muscle from an inflamed appendix or peritoneum
• Anyone with joint pain of unknown cause should be asked about a
recent history of skin rash (delayed allergic reaction, Crohn’s disease).
Special Questions to Ask: Sacrum, Sacroiliac and Pelvis
• Have you ever been diagnosed with ulcerative colitis, Crohn’s disease,
IBS, or colon cancer?
• Are you taking any antibiotics? (Long-term use of antibiotics can
result in colitis).
• Have you ever been diagnosed or treated for cancer of any kind?
(Metastases to the bone, especially common with breast, lung, or
prostate cancer, but also with pelvic or abdominal cancer)
• Do you have any abdominal pain or GI symptoms? (assess for lower
abdominal or suprapubic pain at the same level as the sacral pain; if
the client denies GI symptoms, follow-up with a quick list: Any
nausea? Vomiting? Diarrhea?
• Change in stool color or shape? Ever have blood in the toilet?
• If sacral pain occurs when the rectum is stimulated: Is your pain
relieved by passing gas or by having a bowel movement? Have you
had recent abdominal or pelvic surgery (including hysterectomy,
bladder reconstruction, prostatectomy)?
• Do you ever have blood in the toilet?