Impairment-based examination and disability management of an elderly woman with sacroiliac region pain. (Case Report).

Sacroiliac joint (SIJ) dysfunction often is considered a common source of low back and buttock pain. (1-3) Some authors have suggested that SIJ dysfunction could cause sciatica, (4) buttock and leg pain, (5,6) and a positive straight leg raise. (7) Based on generation of pain referral maps using provocative injections into the SIJ in subjects without symptoms of SIJ dysfunction, Fortin and colleagues (2,3) concluded that common pain patterns include medial buttock pain (which is generally caudal and medial to the posterior superior iliac spines [PSISs]), groin pain, anterior thigh pain, posterior thigh pain, and pain in the superior lateral thigh. It has been reported that SIJ region pain is a potential sequela with pregnancy and childbirth. (8,9) However, it is common practice to associate falls onto the buttocks, as well as abnormal lower-extremity weight-bearing forces, with sprains to the sacroiliac ligaments. (10,11)

Impairments associated with SIJ disorders include pelvic obliquity (positional asymmetry), (1,12-14) innominate active mobility restrictions, (10,11,15-17) and SIJ ligament tenderness. (10) Cibulka and Koldehoff (12) proposed that clinicians typically use a cluster of physical examination findings to diagnose the presence of pelvic obliquity. Two clinical trials (12,18) have demonstrated the usefulness of pelvic obliquity assessment to determine which patients will respond to manipulative procedures intended to affect the SIJ. Several authors (10,11,15,16,19) have suggested using physical examination findings to indicate the direction of innominate mobility impairments in the sagittal and transverse planes. Following identification of the movement impairment, these authors suggested applying innominate mobilization or manipulative procedures to alleviate the specific movement impairment. Reliability, validity, specificity, and sensitivity for tests for innominate mobility impairments, however, have not been reported in the scientific literature.

The findings of some studies (1,13) suggest that a relationship exists among SIJ dysfunction, hip pain, and hip range of motion deficits. In patients with a diagnosis of lumbar sprain, disk herniation, SIJ dysfunction, and avulsion fracture, Ellison et al (20) reported a relationship between low back pain and asymmetrical hip rotation, that is, more lateral hip rotation than medical hip rotation. Cibulka and Delitto (13) reported reducing anterior or inguinal hip pain with a positive Faber test in a group of patients following SIJ manipulation.

The purpose of this case report is to describe the management of a patient with a history suggestive of sacroiliac region pain and a physical examination that suggested innominate mobility restrictions. Hip range of motion deficits were demonstrated and addressed as a separate, coexisting impairment related to the patient's symptoms. The case report also proposes a relationship among the patient's impairments, functional limitations, and disability using the Nagi scheme of physical disablement. (21,22)

Case Description

Patient

The patient was a 74-year-old woman whose symptoms began approximately 18 months prior to her initial physical therapist examination. She reported that while walking in a shopping mall, she tripped over the edge of a carpet and caught herself without falling. She experienced a sudden sharp pain in the left buttock and low back and immediately experienced difficulty weight bearing on her left lower extremity. The pain and difficulty with weight bearing were intermittently disabling for about 1 year. After 1 year, the pain became constant.

Reported Functional Limitations

During the initial physical therapist examination, the patient complained of constant unilateral pain of varying intensity over the left buttock, hip, groin, and upper thigh. This pain awoke her approximately 2 to 3 times per night during position changes. She also reported that lying supine was the most painful position, with right side-lying being the most comfortable position. Both standing and walking were painful, and she could not tolerate full weight bearing through her left lower extremity or walking more than 5 minutes or approximately one city block. The patient's left buttock and hip pain were the primary factors that limited ambulation. She could not recall any injury other than the injury sustained tripping in the mall.

The patient lived with her daughter and grandchildren. Prior to her disability, she was the primary daytime caregiver for her grandchildren while her daughter worked full-time. Caregiving activities included walking her grandchildren to and from school and pushing her youngest grandchild in a stroller to the park. Prior to the onset of her back and buttock pain, she walked 5 times per week, approximately 3.2 km (2 miles) per day while pushing the stroller. At the time of the initial examination, her disability included the inability to walk her grandchildren to and from school or push her grandchild in a stroller to the park, so she was unable to be the primary daytime caregiver for her grandchildren. The patient's goals were to return to her previous level of function, to sleep without disturbance, and to resume her role as the primary daytime caregiver for her grandchildren.

Physical Examination

A systems review, including review of the urogenital, nervous, gastrointestinal, and cardiovascular systems, was conducted and found to be negative. The patient reported that she did not have osteoporosis or any history of back pain prior to the past 18 months. The lumbar spine was examined via central posterior-to-anterior (PA) pressures and did not reproduce symptoms. The PA pressures were applied with an oscillatory force to the spinous processes of the lumbar vertebrae with the patient in the prone position. (23) Good intertester reliability was demonstrated for PA pressures with regard to pain provocation testing (24); however, multiple authors (24,25) have cited poor reliability with regard to lumbar accessory motion testing via PA pressures. The physical examination procedures and the results of the procedures in relation to the patient's mobility and pain are summarized in the following sections.

Sagittal-plane innominate active mobility. (10,11,14,16,17,19) With the patient standing, the examiner (JJG) palpated the inferior margin of the left PSIS with the left hand and a prominent sacral spinous process near the S2 segment with the right hand. The patient was instructed to raise the left knee toward the ceiling to create a relative posterior rotation of the left innominate. The examiner determined whether the left PSIS moved in a caudal direction while being palpated relative to the sacrum (Fig. 1). The examiner then instructed the patient to raise the right knee toward the ceiling to create a relative posterior rotation of the right innominate and extension of the sacrum, palpating the same landmarks as previously described. The examiner determined whether the S2 spinous process moved in a caudal direction while being palpated relative to the left PSIS (Fig. 2).

[FIGURES 1-2 OMITTED]

The sacrum did not move independently in a caudal direction relative to the left PSIS when the patient raised her right knee; rather, both landmarks moved in unison as the right knee was raised. We interpreted this finding as limited anterior rotation of the left innominate. This finding alone would not indicate SIJ treatment for this patient due to contradictory reliability (17) reported for the Gillet test, which is similar to the sagittal-plane active mobility test used in this study, when this test is used independently. Potter and Rothstein (26) reported poor intertester reliability, demonstrated by 46.67% agreement between examiners for 15 patients with lumbosacral and unilatleral leg pain. Herzog et al (17) demonstrated significant intraexaminer and interexaminer reliability among 10 chiropractors with 11 patients with sacroiliac pain. Percentage of agreement ranged from 60% to 79%. However, it is our opinion that this positive innominate active mobility examination, clustered with positive findings during innominate positional symmetry tests and sacroiliac ligament tenderness tests, provides the clinician with stronger evidence indicating that intervention for the SIJ is appropriate.

Transverse-plane innominate active mobility. (10) The patient stood with her knees extended and feet shoulder width apart. The examiner was seated behind the patient and monitored the medial and lateral movement of the patient's anterior superior iliac spine (ASIS) with both hands. The examiner observed the lower-extremity range of motion as the patient medially and laterally rotated her hip, alternately pivoting on the heel of each foot. The examiner determined whether rotation of the innominate and medial and lateral hip rotation were symmetrical (Figs. 3 and 4). Symmetry was determined by the amount of excursion noted at the foot. The examiner noted limited left innominate and hip medial rotation.

[FIGURES 3-4 OMITTED]

Palpation for innominate positional symmetry. Palpation of the right PSIS and left PSIS with the patient in the prone position, as described by Jackson, (10) revealed 2 findings thought to be related to positional symmetry. Palpation of the inferior margins of the left PSIS and right PSIS suggested that both inferior margins were symmetrical with regard to superior or inferior position. Palpation of the medial margins of the PSIS suggested that the medial margin of the left PSIS was more medial to the midline than the medial margin of the right PSIS. Palpation of the inferior margins of the ASIS with the patient positioned supine, as described by Jackson, (10) suggested that the left ASIS was markedly superior (by approximately 1.5 cm) to the right ASIS. Palpation of the anterior-most aspect of the left ASIS and right ASIS indicated that the left ASIS was positioned slightly more posterior (in the transverse plane) than the right ASIS. Potter and Rothstein (26) have demonstrated poor intertester reliability (demonstrated by less than 50% agreement) for assessment of pelvic symmetry via palpation. Subjects were 17 patients treated in 2 outpatient clinics with lumbosacral pain and unilateral lower-extremity symptoms. Percentage of agreement for palpatory measures of symmetry ranged from 35.29% to 43.75%. Levangie (14) reported excellent reliability for measurements of ASIS and PSIS height, evidenced by intraclass correlation coefficients (ICCs) of greater than .99 and moderate reliability for measurements of PSIS and ASIS asymmetry, evidenced by ICCs of .70 to .75. Subjects were 141 patients with low back pain and 133 patients without low back pain.

Palpation for sacroiliac ligament tenderness. The examiner palpated the region of the short posterior sacroiliac ligament just medial to the PSIS, the region of the long posterior sacroiliac ligament inferior to the PSIS, and the sacrotuberous ligament between the sacrum and the ischial tuberosity. (10) The region of the left short posterior sacroiliac ligament and the left sacrotuberous ligament were tender. The right sacrotuberous ligament was not tender to palpation, and the region of the right short posterior sacroiliac ligament was slightly tender but did not reproduce the patient's usual pain. The patient reported that palpation of the region of the left short posterior sacroiliac ligament reproduced her low back pain and that palpation of the sacrotuberous ligament reproduced her left buttock pain. No specific studies were found reporting reliability or validity for specific ligamentous palpation as a provocative test; however, McCombe et al (27) reported potential intertester reliability for pain provocation with palpation over the SIJ and iliac crest. This study demonstrated kappa agreement coefficients of .28 to .50 in 2 patient groups totaling 83 patients. Subjects in group 1 were drawn from an orthopedic practice, and subjects in group 2 were randomly chosen from a group of patients referred for physical therapy with diagnoses of low back pain.

Hip medial and lateral rotation range of motion. Left hip passive lateral rotation was 30 degrees, and left hip passive medial rotation was 10 degrees. Right hip passive lateral and medial rotation were both 45 degrees. Ellison et al (28) established good interrater and intrarater reliability among 3 examiners for both goniometer and fluid-filled inclinometer measurements of hip rotation in 22 volunteers without low back dysfunction and inclinometer measurements for 15 patients with low back dysfunction. The authors reported ICCs ranging from .95 to .99 for inclinometer measurements. No significant differences between inclinometer and goniometric measurements were found using t tests to compare the means.

Evaluation

The physical examination findings suggested that the patient's functional limitations and disability were due to mobility impairments of the left innominate. The patient's innominate active mobility examination suggested that the innominate was limited in sagittal-plane anterior rotation and transverse-plane medial rotation. The restriction in left hip medial rotation supported a transverse-plane mobility impairment. The positional asymmetry of the patient's ASISs suggested that the left innominate was held near its end range of superior translation and posterior rotation in the sagittal plane and lateral rotation in the transverse plane. We suspected that the innominate mobility impairments and positional asymmetries, led to constant strain on the left sacrotuberous ligament, which caused it to be tender to palpation. (10) It is our opinion that palpable tenderness in the region of the short posterior sacroiliac ligaments is not necessarily predictive of a specific innominate mobility impairment or positional asymmetry due to the multidirectional fibers of this ligament and the fact that it restrains multiple sacral and innominate motions. (10) However, because palpation of the region of the posterior sacroiliac ligament and sacrotuberous ligament reproduced the patient's pain, initially addressing potential impairments of the innominate seemed reasonable as opposed to, for example, initially addressing impairments in the lumbar spine or hip articulations. It should again be noted that we did not assess the reliability or validity of the examination techniques used; therefore, clinical decision making was driven by the history, clusters of positive physical examination findings, and response to direct intervention. For the purposes of this case, we were satisfied with the reliability of our measurements based on the patient's favorable response to treatment interventions, which were directly guided by the aforementioned measurements. We acknowledge that there is an element of uncertainty in this method of examination. Thus, the patient was continually re-examined following each intervention to determine whether her function improved.

Intervention

Session 1

Following the examination, direct intervention was initialed. The first impairments addressed were the sagittal-plane mobility restrictions of the left innominate. To attempt to restore the left innominate's inferior translation and a more neutral or symmetrical position within the SIJ (and relative to the right innominate), inferior glide manipulations of the left innominate were performed. The patient was positioned supine, and 3 high-velocity, small-amplitude thrusts were applied in an inferior direction via a traction-type pull on the patient's left ankle (Fig. 5). (11) Following innominate manipulations, some authors (10,16,19) have recommended having the patient do an isometric contraction of the hip adductors. This procedure consists of a bilateral, isometric contraction of the hip adductors with the patient positioned supine with knees and hips flexed and is intended to ensure that the pubic bones are optimally aligned as they form the articulation across the pubic symphysis. (10,16,19) The patient was asked to contract to maximum ability. The contraction was held for 5 second and repeated 5 times, with a 5-second rest period between contractions. Following these procedures, their effect on the patient's impairments was examined. The patient's left sacrotuberous ligament remained tender to palpation. The symmetry of the left and right ASISs was improved, but the level of the left ASIS was still superior to that of the right ASIS. Active mobility testing of the left innominate continued to suggest limited mobility in sagittal-plane anterior rotation. The patient reported that her low back pain was less than before treatment and that walking was easier, with increased ability to weight bear on the left lower extremity.

[FIGURE 5 OMITTED]

Because treating the left innominate mobility impairments appeared to partially alleviate the patient's symptoms, the therapist (JJG) concluded that additional treatment of the pelvic girdle was indicated during the initial treatment session. The therapist decided to next address the sagittal-plane rotational impairment and associated sacrotuberous ligament tenderness. An isometric manipulation procedure using simultaneous contraction of the left hip flexors and the right hip extensors was performed (Fig. 6). (10) This isometric contraction was repeated 5 times, holding for 5 seconds at the maximum tolerated resistance, with a 5-second rest period between contractions. Following this procedure, an isometric contraction of the hip adductors was performed, as described previously. After these procedures, left innominate anterior rotation mobility appeared to improve. The examiner took care to apply a uniform amount of pressure, and the patient reported decreased tenderness over the left sacrotuberous ligament. Following isometric manipulation, the patient also reported an additional decrease in pain, especially with walking. This re-examination was completed to determine whether the patient's condition improved or worsened following the innominate manipulation strategy. The patient was given 2 isometric manipulation exercises to perform at home daily. These exercises were the same exercises done during the initial treatment and included supine isometric left hip flexion and right hip extension followed by supine isometric hip adduction, both done with a 5-second hold, repeated 5 times, once daily. The patient was scheduled to return for physical therapy in 2 weeks. A 2-week follow-up was necessary because the patient needed at least 1 week's notice to schedule transportation.

[FIGURE 6 OMITTED]

Session 2

Upon review of her functional limitations, the patient reported that she was able to walk her grandchildren to school and that she experienced mild pain only on the walk home, which prompted a seated rest. She noted increased ability to weight bear on the left lower extremity. She also reported improved ability to sleep positioned supine, with only 1 to 2 episodes of sleep disturbance per night. She stated that left buttock and groin pain had decreased. Re-examination of her impairments suggested normal innominate active mobility in the sagittal plane, restricted innominate medial rotation in the transverse plane, normal symmetry of the right and left PSISs and ASISs, and slight tenderness over the left sacrotuberous ligament and left short posterior sacroiliac ligament region. Left medial hip rotation was unchanged. The manipulative and isometric manipulation procedures applied during the previous visit were repeated. Re-examination following this direct intervention indicated no change in the patient's gait, ligament tenderness, or hip range of motion. The patient reported, however, that her low back, left buttock, and groin pain were improved compared with when she arrived for treatment. Isometric manipulation procedures using the left iliacus were then applied to provide a medial rotation force to the left innominate (Fig. 7). After treatment, the patient's hip medial rotation range of motion had increased by 10 degrees. Lastly, a contract-relax-stretch to left hip lateral rotators was performed, and the patient was scheduled to return in 2 weeks.

[FIGURE 7 OMITTED]

Session 3

The patient reported that she was able to walk her grandchildren to school and back without the need for a rest. She stated that she was sleeping without disturbance and performing her exercises regularly. A re-examination suggested normal innominate sagittal-plane mobility, symmetry of the PSIS and ASIS landmarks, no sacrotuberous ligament tenderness, and mild left short posterior sacroiliac ligament region tenderness. The leg rotation test to assess active innominate medial rotation in the transverse plane continued to demonstrate left lower-extremity medial rotation. Left hip passive medial rotation remained at 20 degrees. To increase medial rotation, a stretch was added to the home exercise program (Fig. 8). Standing with her back to the chair, the left knee was bent to 90 degrees with the lower leg supported on the chair. The patient was instructed to rotate her trunk to the left and hold for 30 seconds and to repeat this stretch 3 times, twice daily. She was asked to focus on this new exercise and to discontinue the home exercises previously described. She was again scheduled for a follow-up appointment in 2 weeks.

[FIGURE 8 OMITTED]

Session 4

When the patient returned for her fourth treatment, she reported that she was able to walk her grandchildren to and from school, was able to push the stroller with her grandchild 3.2 km to the park, and was sleeping through the night, all without pain. The leg rotation test continued to demonstrate innominate transverse-plane mobility limitations, and left hip medial rotation was limited to 25 degrees. In addition, tenderness remained when palpating the left short posterior sacroiliac ligament region. This session include re-evaluation and review of home stretching. The patient was reminded to continue her home exercise to improve left hip medial rotation, and she was discharged from physical therapy.

Discussion

A 74-year-old woman with an 18-month history of low back, left buttock, and groin pain was examined and re-examined using a cluster of SIJ tests that focused on innominate active mobility, positional symmetry, and ligament tenderness. The test results suggested impairments, which were addressed using manual procedures and therapeutic exercises. We hypothesized that reducing the innominate mobility, positional asymmetries, and ligament abnormalities were related to the reduction in functional limitations and disability that the patient reported.

Brooke (29) reported that, in women of advanced age, some SIJ motion persists and that ankylosis was not present in any of the 105 female cadavers examined. Other researchers (30,31) have also found that the SIJs of relatively old women (20 of 24 specimens were women over 60 years of age) demonstrated flatter auricular surfaces than men's joints, which is suggestive of greater mobility. Thus, we believe that elderly female patients with low back pain consistent with sacroiliac region pain referral patterns and a mechanism of injury suggestive of SIJ dysfunction should be screened for SIJ involvement.

We used the Nagi model to relate the patient's impairments to her functional limitations. We believe that attempting to identify this relationship is important for planning treatment because many patients have numerous impairments that are unrelated to their functional limitations. (21) As Jette reported, the goal of the Nagi disablement scheme is "to delineate the major pathways from disease or active pathology to various types of functional consequences." (22)(p381)

Although authors have argued against the reliability of measurements obtained with individual tests for assessing SIJ dysfunction, (14,26,32) the use of a cluster of tests has demonstrated increased specificity, sensitivity, and intertester reliability over individual SIJ tests in some studies. (12,33) Cibulka and Koldehoff (12) used the standing flexion test, sitting PSIS palpation, supine long-sitting test, and prone knee flexion test and reported that 3 of the 4 tests must be positive to determine the presence of SIJ dysfunction. This cluster was also successfully used to determine which patients with low back pain would benefit from manipulation intended to affect the SIJ. (18) Levangie (14) assessed the association of individual tests and their relationship to low back pain and found that only the Gillet test demonstrated a strong positive association to low back pain. The sagittal-plane innominate active mobility examination procedure, which we used, is similar to the Gillet test. Levangie noted that "the stronger association between the Gillet test results and low back pain as opposed to measurements of innominate torsion might support the contention that the Gillet test assesses sacroiliac joint hypomobility and that it is the hypomobility rather than the innominate torsion that leads to low back pain." (14)(p1054)

The cluster of tests that we used is intended to identify innominate mobility impairments as well as sacroiliac ligamentous strain and innominate positional asymmetries associated with the specific mobility impairment. The results allow the therapist to hypothesize the specific innominate mobility impairments, which guide selection of manipulative procedure and therapeutic exercise. The reliability, validity, sensitivity, and specificity for this cluster of tests are unknown. We believe that the absence of this information requires continual re-examination to determine potential effects of the interventions.

We suspected that mobility impairments of the left innominate in the sagittal plane were the primary impairment contributing to the patient's limited ambulation tolerance. The left innominate's inability to translate inferiorly on the sacrum, from its superiorly translated position, presumably caused ligamentous strain and the associated pain with continued weight bearing. Following 18 months of left low back, buttock, and groin pain, which was unrelenting for the final 6 months, we provided intervention purported to affect innominate mobility and position. Because the patient experienced improvement immediately following physical therapy intervention, it appears likely that symptom resolution was not due to natural recovery. Therefore, it seems appropriate to conclude that the use of this cluster of SIJ evaluative tests and the disablement model warrants further investigation.

This case report cannot determine whether the cluster of tests used is indeed a reliable means of diagnosing SIJ dysfunction. Further research is warranted to determine whether this cluster of SIJ tests is a sensitive, specific, and reliable means of evaluating innominate impairments. In retrospect, a standardized outcome measure would have provided a stronger case to document patient improvement and treatment effectiveness. Research to examine the effectiveness of manual therapy intervention versus a control group, using a standardized outcome measure, would also be beneficial in determining the effectiveness of this examination and treatment strategy.

References

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JJ Godges, PT, DPT, MA, OCS, is Coordinator, Kaiser Permanente Southern California Orthopedic Physical Therapy Residency, Los Angeles, Calif, and Assistant Professor, Department of Physical Therapy, Loma Linda University, Loma Linda, Calif.

DR Varnum, PT, BS, is Staff Physical Therapist, Kaiser Permanente, Long Beach, Calif.

KM Sanders, PT, DPT, ATC, CSCS, is Director, San Luis Sports Therapy and Orthopedic Rehabilitation, San Luis Obispo, Calif. Address all correspondence to Dr Sanders at 1306 Johnson Ave, San Luis Obispo, CA 93401 (USA) ([e-mail]).

All authors provided writing. Dr Godges provided concept/project design, facilities/equipment, and institutional liaisons. Dr Godges and Ms Varnum provided data collection and subjects. Dr Sanders provided clerical support and consultation (including review of manuscript before submission).

This article was submitted March 14, 2001, and was accepted March 13, 2002.

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