Download Pudendal Nerve Palsy - Prepartum Pelvic Pain

Sacroiliac
Joint
Sacroiliac Joint Pain
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22% of pregnant women report having some form of pain that
originates from the pelvis itself. Between 5 and 8% of this
percentage experience disability and severe pain (Daly, et
al). A common source of pelvic pain during pregnancy includes
the Sacroiliac joints.
The pregnant patient often presents with an excess lumbar
lordosis as a result of the increased abdominal
weight. Ligaments also become more lax as a result of
hormonal changes and the sacroiliac joints often exhibit an
asymmetry in the amount of laxity. With these factors combined
there is increased stress at the low back and pelvis, as well as
compensations throughout the trunk and
extremities. Orthopedic conditions, pain, and disability can
occur as a result of these factors. (Goldsmith, et al). Other risk
factors for pelvic pain in pregnant women are multiparity,
obesity, previous cesarean birth, young maternal age, manual
labor occupation, and stress (Bjelland et al).
Patient Presentation
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Pain occurs in episodes and is aggravated by twisting motions such
as turning in bed or within 30 minutes of the SIJ’s being loaded during
sitting, standing, walking, or ascending/descending stairs.
Nighttime may be when the pain is worst as a result of loading
throughout the day. (Keriakos et al)
The pubic symphysis can also be involved and should be screened
for by asking the patient about any pain in the groin area.
Pregnant patients may or may not attribute the mechanism of injury
to a traumatic event, such as a fall (Cusi,et al). Pelvic girdle pain is
often characterized as being a stabbing or sharp pain on one side
that occurs within 1cm inferomedial to one the posterior superior iliac
spine. This is considered to be the Fortin Finger Test. To meet these
criteria for a positive test, the patient must use one finger to directly
indicate the area of pain on their body on more than one
occasion. It is suggested to be performed immediately after Patrick’s
Test and to be followed by other diagnostic tests (Fortin et al). Pelvic
girdle pain can refer to the inner thigh, hip, or groin area and patients
may complain of a “clicking” in the pelvis.
Examination
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A subjective history including the severity and irritability as well as
functional limitations and participation restrictions is necessary. Be
sure to include the nature of the onset of pain.
A body chart of all related symptoms is useful and should be
corroborated with palpation of bony structures including the pubic
symphysis and SI joints. There are many tests to help the clinician
determine if the pelvis is the true origin of pain.
A leg length discrepancy, observed dysfunctional active motion at
the SI joints, distraction and compression of the sacroialiac joints,
posterior pelvic pain provocation test, and hip adductor manual
muscle test can help the clinician to rule in sacroiliac dysfunction in
the pregnant patient when these tests are positive and assist in
ruling out pain referral from the lumbar spin. Active straight leg
raise is contraindicated during pregnancy since it involves active
hip flexion in supine.
To determine functional limitations, the patient specific functional
scale can be utilized.
Special Considerations
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After the 1st trimester (12 weeks), the supine position
should be limited to 1-3 minutes at a time and prone
is contraindicated. Active hip flexion in supine
should be avoided as well.
Ultrasound treatment near the trunk is
contraindicated and electrical stimulation is a
relative contraindication that should be discussed
with the physician.
**Other questions to consider are bowel & bladder
changes, decreased sensation in lower extremities,
constitutional symptoms, sudden edema of hands or
feet, and pain in lower extremities or lumbar area.
Common Treatments
 Muscle
energy techniques/strengthening to
improve stability of the pelvis, specifically
targeting multifidus and transverse
abdominus.
 Sacroiliac belts which should be placed over
the greater trochanters.
References
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Bjelland, EK, Eskild, A, Johansen, R, and Eberhard-Gran, M. Pelvic Girdle
Pain in Pregnancy: The Impact of Parity. American Journal of Obstetrics
and Gynecology 203(2):146 e1-6, 2010.
Cusi, M. Paradigm for Assessment and Treatment of SIJ Mechanical
Dysfunction. Journal of Bodywork and Movement Therapies (2010)
14,152-161.
Daly, JM, Frame, PS, and Rapoza, PA. Sacroiliac Subluxation: A Common
Treatable cause of Low Back Pain in Pregnancy. Family Practice
Research Journal 1991; 11:149-159.
Fortin, JD, Dwyer, AP, West, S, and Pier, J. Sacroiliac Joint: Pain Referral
Maps upon applying a new Injection/Arthrography Technique. Part I:
Asymptomatic Volunteers. SPINE Volume 19, Number 13, pp 1475-1482,
1994.
Goldsmith, LT, Weiss, G, and Stienetz, BG. Relaxin and its role in
pregnancy. Endocrinology and Metabolism Clinics of North America
1995; 24:171-186.
Keriakos, R, Bhatta, SR, Morris, F, Mason, S, and Buckley, S. Pelvic Girdle
Pain and Puerperium. Journal of Obstetetrics and Gynaecology Oct
2011; 31(7); 572-80.