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Tough case
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Tough case - July 29, 2007 11:59:16 PM
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sslevins
Posts: 15
Joined: June 27, 2006
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Hello all,
I would appreciate any suggestions with this patient.
Hx of severe left SI joint pain. Did have MVA months ago and states leg was braced on pedal when struck from behind.
Does not appear to be related to lumbar spine- no increase in / change of pain with lumbar motions / PA mobs..
tight hams, negative SLR, negative slump,
reproduction of pain is only with any sacral nutation pressure (even very light) and with compression through the left leg.- with left leg traction distraction pain is ok but as soon as released pain returns.
He does have apparent right rotated ilium with upslip but have tried MET and mobs for such with little relief.
Any thoughts?
He is a "large" man and therefore palpation of pelvic markers is not really easy.
Steve
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RE: Tough case - July 30, 2007 8:28:02 AM
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Shill
Posts: 1092
Joined: February 13, 2003
From: Madison WI USA
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How old is this gentleman, and has he had films of the hip/pelvis? If so, these will be a more accurate indicator of pelvic continuity/alignment than palpation, not to mention the potential for hip joint pathology, given the pain with weightbearing.
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RE: Tough case - July 30, 2007 11:17:54 AM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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do me a favor:
do a ASLR test and a bit more of the following tell me the results and i will then have an opinion:
have him supine, actively straight leg raise good leg. If tough or painful approximate his asis by essentially squeezing together his pelvis anterior and midline, se iff pain is worse or if easier and less pain. Do the same but gap open by crosssing hands and pushing lateral and posterior at asis while he repeats the active straight leg raise with good leg, note any changes, re do with bad leg. Push Directly posterior on asis on both sides try to feel a difference if one is easier to move than the other or more play or less play. Push at all 4 quadrants in a prone position on his sacrum, at the top left top right bottom left and bottom right feel forplay and if pain ful etc. when he is just lying there, which direction do his feet turn, good and bad. how is piriformis at end range compared side to side. you sure SLR is negative, even with ading internal rotation and dorsiflexion?
get back to me and i'll get back to you...
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RE: Tough case - August 12, 2007 7:14:32 PM
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jddufault
Posts: 22
Joined: July 31, 2007
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FLA,
could you please fill me in on what diagnostic info compressing/distracting the SIJ and then performing an ASLR gives you? This one is new to me.
Thanks for the time.
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RE: Tough case - August 13, 2007 8:17:27 AM
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sslevins
Posts: 15
Joined: June 27, 2006
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FLAOrtho,
Sorry for the delay- ASLR test painful for all except right SLR with ASIS distraction (SI compression). No significant diff with ASIS pressures. Of the 4 quadrants of sacrum- pain on both inferior quadrants. Infact pain is severe at tip of sacrum and to coccyx. SLR is definitely negative. Piriformis slightly tight bilaterally with no side to side differences.
When he is lying down he says he is more comfortable as long as one or the other (doesn't matter which) leg is bent up at the knee.
I as well as jddufault will wait to here how the ALSR testing helps. I am assuming that it is a type of test of force / form closure to see if increased stability to the SI joint results in less pain- ie in this case the compression at the SI joint decreased the pain. But I will tell you that an SI belt was tried in the past- perhaps it was not done right and I need to attempt again.
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RE: Tough case - August 13, 2007 9:36:11 AM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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yeah, you have an instability there. Most SI belts do the approximation and bias towards force closure of the theoretical anterior fibers of the SI joint, while you were actually theoretically closing the posterior giving it stability there. There is only one SI belt that can even attempt to do the job right for this case, diane lee's belt, allows yo to adjust for directional forces. But stick with just stabilizing the joint.
progression: have the patient supine hook lying, and with ball between knees squeeze ball, activate abs, and do very mini bridges in partial range without lowering all the way back down to table. Same thing with theraband wrapped around knees while pushing out into it.
Teach patient to avoid ALL large motions of legs, no big steps, stairs one at a time, two legs to stand up, two legs to get out of car etc...
patient prone, knee flexed, manually resist IR and ER in a rhytmic stabilization manner with medium force at the neutral positions though...have the patient keep his leg there while you apply pressure rather than other way around...do this both legs.
Leg press or total gym: bilateral mini squats partial range.
Supine: have patient lay on top of blood pressure cuff...inflate it to around 40 mmHG when they are at rest, should be behind small of back in the lordosis. Teach them a post pelvic tilt using the BP cuff as biofeedback. Have them push until it gets to around 60-80 but no harder. Have them hold it there while breathing for the first step. when they can do that, progress to keeping that pressue while in hook lying and slowly march up with one leg and slowly down and then the other while breathing and keeping that pressure between 60-80 on way down, may go up higher while on way up, progress this as they progress session to session adding in leg straight, both legs hooked, both legs straight, ball between legs bent, theraband legs bent, adding tubing from upper corner of plynth with diagonal type opp arm with theratubing meeting opposite leg, all the while keeping the pressure. get creative...
finally, you manually get the SI in a place where the SLR does not hurt. Hold it there. Hold it there while the patient does some functional movements leg mini bridges, or mini SLR, mini abductions, etc. Neuromuscularly this will help re-train as well.
as long as patient doesn't do anythign to tweak it, should be steady progress.
have fun-
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RE: Tough case - August 13, 2007 3:09:10 PM
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plhunter
Posts: 41
Joined: March 5, 2006
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I agree with the above post but would rather not have them do a posterior pelvic tilt but teach them to contract the Transverse Abdominals with the BP cuff and then progress to holding the contraction with movement. I would use a therapeutic ball with TrA contraction advancing with movement. Do manual fascia release to lumbar/diaphram with SI joint decompression.
Peggy
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RE: Tough case - August 13, 2007 5:58:05 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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posterior directed but as you can see by the minimal change in pressure i am bringing them more towards a neutral, but easier to explain to have them going posterior direction, but agree with everything else!
then again lot's of naysayers here say SI doesn't cause problems...
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RE: Tough case - August 14, 2007 11:08:07 AM
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jlharris
Posts: 476
Joined: April 12, 2006
From: Nebraska
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SI causes loads of problems. Just have to put it near the bottom of your differential Dx list for older pt's (eg > 60) as the literature shows the SI ligaments are completely calcified/fused by that age. That's all. If it's a 20 year old women with obvious inominate rotaions/flares/up slips and or positve pain provacation tests (as you suggested earlier to do) "directed" as the SI, then SI should be at the top of your differential Dx list.
Just don't fall into the trap of assuming everything is related to the SI. Or lumbar spine, or LLD, or sphenoid rotation, or...you get the point.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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RE: Tough case - August 14, 2007 6:02:17 PM
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jesspt
Posts: 85
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From: Illinois
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Wouldn't worry about the positional palpatory tests too much, for all of the various reasons that have been stated on numerous threads here and at My PT Space.com. The provocation tests are another story, though.
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RE: Tough case - August 14, 2007 8:20:43 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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then again you take an old lady who has a pseudo fused DI let her slip and fal and boy will she be in some pain, and it will be hypermobile with respect to her normal
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RE: Tough case - August 14, 2007 10:21:50 PM
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jlharris
Posts: 476
Joined: April 12, 2006
From: Nebraska
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quote:
ORIGINAL: FLAOrthoPT
then again you take an old lady who has a pseudo fused DI let her slip and fal and boy will she be in some pain, and it will be hypermobile with respect to her normal
No doubt. But should SI be at the top of your differential Dx list? My opinion, based on the literature, says no. I didn't say eliminate it. But for our little old lady after a traumatic fall our hypothetical DD list may look like this:
1. Hip fx
2. Contusion
3. Compression fx
4. SI "hypermobility"
Again, no need to eliminate it. I feel it's just important to not expect it first in all cases. Use what has been shown in the literature to help us decide what the MOST LIKELY source of pain is. Which, for our little old lady, could be her SI in the end (no pun intended). No doubt about that.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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RE: Tough case - August 15, 2007 9:04:25 AM
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FLAOrthoPT
Posts: 1011
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From: West Palm Beach
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yeah but if someone is really putting a hip Fx in the same diff list as an SI? huh? i know you were doing it in the instance of a supposed fall without seeing a patient, but come on i think a student can rule out a hip Fx as a source of pain and not include it in their differential
stop playing devil's advocate, there is no need when we are already assuming we have narrowed down the dx to SI in this thread
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RE: Tough case - August 15, 2007 5:10:19 PM
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jlharris
Posts: 476
Joined: April 12, 2006
From: Nebraska
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Good point. I got off topic. Was just trying to exaggerate to get the point across.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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RE: Tough case - August 15, 2007 5:47:04 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
Status: offline
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no prob point gotten (how bout them there english for ya)
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