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Case Reports |
HT Vaughn, PT, DPT, OCS, MTC, is Senior Lecturer, Physical Therapist Assistant Program, Southern Illinois University at Carbondale, 374 E Grand Ave, Mail Code 6740, Carbondale, IL 62901 (USA), and Senior Physical Therapist, Select Medical Corporation, NovaCare Rehabilitation, Benton, Illinois
W Nitsch, PT, PhD, MTC, is Director, Doctor of Physical Therapy Program, University of St Augustine for Health Sciences, San Diego, California
Address all correspondence to Dr Vaughn at: tvaughn{at}siu.edu
Submitted August 19, 2007;
Accepted July 28, 2008
 | Abstract |
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Case Description: The patient was a 21-year-old, female collegiate tennis player who developed a right anterior ilial rotation hypermobility as a result of her tennis stroke. Functional limitations were related to sitting, squatting, gait, and playing tennis. Treatment interventions consisted of massage, joint manipulation, stretching, stabilization exercises, sport-specific exercises and modification of tennis stroke, proprioceptive taping, and the use of a sacroiliac belt.
Outcomes: After 26 weeks (33 treatments), tissue tenderness of the sacroiliac joint region was normalized, pelvic/trunk and lower-extremity mobility and flexibility were restored, sacroiliac symmetry and stability were regained, and the patient achieved her goal of returning to competitive tennis at the collegiate level.
Discussion: The patient's right ilial anterior rotation hypermobility was directly related to the mechanics of her tennis stroke. Her outcomes suggest that rehabilitation should focus on the entire abdomino-sacro-pelvic-hip complex, addressing articular, neural, and muscular inhibitions and deficiencies.
| Introduction |
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 TopAbstract Introduction Patient History/Review of...ExaminationEvaluationInterventionOutcomesDiscussionConclusionReferences |
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It is well accepted that the SIJ can be a pain generator.1,3 "Sacroiliac joint syndrome" is a term that has been used to describe pain believed to originate from structures of the SIJ such as the synovial membrane and joint capsule.4 Pain mapping studies suggest that the SIJ may manifest as low back pain, sciatica, or trochanteric pain. The medial portion of the buttock, at the junction with the sacrum, is the most typical site of pain from the SIJ. However, pain radiating to the posterolateral aspect of the greater trochanter and lower buttock and to the posterolateral aspect of the thigh is common.4–7
In previous research,8–16 provocation tests and patient-reported symptoms utilized alone or in combination were found to lack sensitivity and specificity for diagnosing SIJS. In addition, imaging studies of the SIJ do not distinguish patients who are asymptomatic from those who are symptomatic, and the SIJ double anesthetic block as the diagnostic gold standard is in question.4,10,13,17 Other investigations18–21 have shown that combining selected tests can improve sensitivity and specificity when diagnosing SIJS. Laslett et al19 reported the likelihood ratio of 3 or more positive tests as 4.27 and the likelihood ratio of 3 or more negative tests as 0.08. Research regarding the reliability of administering SIJ provocation tests has demonstrated conflicting results.22–25
Provocation tests and the SIJ double anesthetic block may lack sensitivity and specificity for diagnosing SIJS because the pain patterns believed to have their source within the SIJ are related to extra-articular structures.10,13,19,25 "Sacroiliac joint dysfunction" is a term used to describe other components of the somatic system, such as the myofascial structures and ligaments, that could become sensitive to pain in the presence of impaired or altered function of the pelvis. Paris and Loubert defined joint dysfunction as "a state of altered mechanics, either an increase or decrease from the expected normal, or the presence of an aberrant motion."26(p46) Sacroiliac joint dysfunction manifests as a mobility impairment that is identified based on the type of motion dysfunction (hypomobility or hypermobility) and the direction of the abnormal movement.1,2,26
Hypomobility of the pelvis may affect its force attenuation properties and cause increased mechanical stress to the hip and lumbar spine. In this scenario, the pelvis is not the source of the pain, but functionally causes pain secondary to increased mechanical stress to neighboring joints and ligamentous structures.2 Hypermobility is common in patients with recurrent SIJD and often can lead to chronic pain.1 Hypermobility can occur when there is a loss in the functional integrity of the myofascial or osteoarticular and ligamentous components that provide stability. Displacement (positional faults) occur when the hypermobile joint overrides the articular prominence.2
It is estimated that SIJD may account for as much as 20% of unexplained low back pain in the general population.12,27–29 Currently, there is no single historic indicator or clinical examination technique that is both sensitive and specific for the diagnosis of SIJD.1,28 The diagnosis of SIJD is a process that includes integrating and evaluating the examination data. The initial examination is a comprehensive screening and specific testing process that leads to a diagnostic classification. The examination consists of a thorough history and interview, a systems review, and selecting and administering tests and measures.30 Accurate diagnosis is based on the combination of historic clues, along with findings from static palpatory examination, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.1,2,31 Although SIJD as a source of lumbosacral pain is widely accepted, the criteria for diagnosis have not been established.
Accurate diagnosis of the type of SIJD is essential in determining the appropriate therapeutic approach. When the dysfunction is diagnosed as hypomobility, the treatment typically includes manipulation of the restricted soft tissues and joint structures, stretching of shortened muscles and fascia, and exercises and activities that promote a full range of movement.26,32 When the dysfunction is diagnosed as hypermobility or instability, the treatment typically includes instruction in correct posture, stabilization exercises, correction of any limitations of movement in neighboring joints that may be contributing to the hypermobility, and use of external support, if needed.26,32 The treatment approach for a positional fault is the same as for a hypermobility dysfunction, except joint manipulation techniques may be required to reduce the displacement.26,33
Sporting activities transmit a tremendous amount of force to the spine and pelvis. Sacroiliac joint dysfunction is a common problem in elite athletes that has been largely unstudied.33 One study, examining the United States Senior National Rowing Team, indicated a prevalence of SIJD in 54.1% of team members.34 Similarly, lumbosacral dysfunction has been described in cross-country skiers.35 Tennis is a sport in which players may be susceptible to SIJD because of the significant amount of biomechanical stress that is placed on the pelvis. The purpose of this case report is to describe examination and intervention techniques used in the diagnosis and treatment of a female collegiate tennis player with a right ilial anterior rotation hypermobility.
| Patient History/Review of Systems |
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The patient reported that she was left handed and that she hit most of her forehand and backhand shots with both hands to compensate for her lack of physical size. She noticed that her 2-handed backhand stroke was especially painful on her follow-through and that she was unable to lunge forward with her right leg behind her on drop shots at the net. She also reported that she was having difficulty attending classes because her overall mobility was severely limited and that she was having considerable pain in sitting. Her goal was to return to her tennis team and #3 singles position.
Based on the location of pain, the complaint that the right leg felt longer than the left leg, and her symptoms aggravated by her 2-handed backstroke and right hip extension, the patient's primary problem was believed to be related to SIJD. Screening of the lumbar spine was performed to rule out a neurological dysfunction. This screening included myotome testing of L2–S1, reflex testing of L4 and S1, sensory testing of the lower extremities for crude touch and pinprick, and passive mobility testing.36 The screening of the lumbar spine was negative for a neurological dysfunction. No structural abnormalities or mobility impairments were identified when screening the ankles, knees, and feet.
| Examination |
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TopAbstractIntroductionPatient History/Review of...ExaminationEvaluationInterventionOutcomesDiscussionConclusionReferences |
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Pain Intensity Level
The patient rated her pain in the right SIJ region as 8 out of 10 on a verbal pain scale ranging from 0 to 10, where 0 was "no pain" and 10 was "the worst pain possible." She rated her worst pain as 8 out of 10 when sitting, standing, or walking and the least pain as 6 out of 10 when lying on her left side with pillow support between her knees. The 11-point rating scale of pain intensity has been found to yield reliable measurements when used by patients with low back pain.37,38
Observation/Gait Analysis
Gait was observed from the anterior view as the patient entered the clinic. She demonstrated a right antalgic gait pattern when ambulating 5 m at a self-selected pace on a level surface.39 She sat with decreased weight bearing through the right pelvic region, and a painful affect was observed.2,33,39
Posture and Alignment
The patient was asked to stand in her most comfortable position and was observed from the posterior view. She exhibited decreased weight bearing of the right lower extremity as she kept the right hip flexed and laterally (externally) rotated. She was instructed to position her feet shoulder width apart with her toes pointing straight ahead while standing. Palpating from a posterior view revealed that the right iliac crest was elevated compared with the left iliac crest and that the inferior lateral angles of the sacrum were level.39 Palpating from an anterior view, the right pubic tubercle was positioned inferiorly compared with the left pubic tubercle, and palpating from a lateral view, the right pelvic inclination angle (Nelaton's line) was greater than the left pelvic inclination angle.40 Nelaton's line is an imaginary line drawn from the inferior aspects of the posterior-superior iliac spine (PSIS) to the anterior-superior iliac spine (ASIS). The ASIS is normally lower than the PSIS and forms an 8- to 10-degree angle.39 Palpating with the patient in a sitting position also revealed the right iliac crest to be elevated compared with the left iliac crest height from a posterior view.39
Palpation-based methods of the pelvis, when used alone, have demonstrated poor diagnostic value in patients with long-term nonspecific low back pain.41 Investigations of palpation-based methods in patients diagnosed with SIJD have not been performed. The patient was asked to demonstrate the tennis stroke that significantly exacerbated her pain. She demonstrated her 2-handed backhand stroke (left-handed) and complained of increased pain when the right hip moved into extension.
Active Mobility Testing
The patient exhibited segmental mobility in the lumbar-thoracic spine with left frontal-plane side bending, as evidenced by a good "C" curve.42 Bilateral trunk rotation was asymptomatic while observing contralateral side bending in the lumbar spine.42 Right frontal-plane side bending and forward bending were limited at end range secondary to the patient complaining of pain in the right sacroiliac region.39 Backward bending was within normal ranges, with no increase in pain.42
Decreased posterior rotation of the right innominate was observed with the Gillet test as compared with the left innominate. The Gillet test is a standing active mobility test used to examine posterior rotation of the pelvis.39 It is performed by palpating the inferior portion of the PSIS and S2 protuberance with each thumb as the patient actively flexes the hip above 90 degrees, alternating left and right while in single-leg support.39 The patient stated that she had difficulty flexing her right hip above 90 degrees. Outflare and inflare of the innominates were tested in a standing position as the patient medially (internally) and laterally rotated each lower extremity with the leg extended forward and the heel on the ground. The medial portion of the PSIS and the S2 protuberance was palpated with each thumb as the patient alternated rotating her lower extremities.2 Outflare is assessed with lateral rotation of the femur as the PSIS is palpated to move in a medial direction, and inflare is assessed with medial rotation of the femur as the PSIS is palpated to move in a lateral direction.2
Anterior and posterior translation of the innominates were tested in a standing position as the patient shifted her weight over and extended her lower extremity. The PSIS and the S2 protuberance were palpated as the patient shifted her weight from side to side.2 Decreased posterior translation of the right PSIS on the sacrum was palpated in comparison with the left PSIS. Movement-based testing has demonstrated poor reliability and very little diagnostic value for detecting SIJD.8,23 The sacral base could not be palpated on the right side secondary to increased tissue reactivity and swelling. Subsequently, direct sacral nutation and counternutation could not be examined.
Range of Motion
The examiner measured range of motion with a 30.48-cm (12-in) plastic goniometer.* Measuring hip active range of motion with a goniometer has demonstrated reliable results.43 Gogia et al44 have reported intraclass correlation coefficients of .98 for intertester reliability and validity for goniometric measurement of the knee. End-feels were assessed at the end of the range of motion and were classified as hard, firm, or soft.45 The reliability of end-feel measurements has not been demonstrated. With the patient positioned supine and the left lower extremity extended, right passive hip flexion was measured as 100 degrees, with a hard end-feel.40 Left passive hip flexion was measured as 130 degrees, with a firm end-feel. Right hip abduction was measured as 20 degrees and was pain limited compared with 40 degrees, with a soft tissue stretch, on the left.40 Medial and lateral rotation of the hip were measured with the patient in a prone position and the knee flexed to 90 degrees.36 Right hip medial rotation was measured as 0 degrees and was pain limited, whereas left hip medial rotation was measured as 35 degrees, with a firm end-feel. Right hip lateral rotation was comparable to left hip lateral rotation (45°), and both exhibited a firm end-feel. The patient reported increased pain with hip extension past neutral in the side-lying position.
Muscle Length
Hamstring muscle length was tested with the patient positioned supine and the low back and sacrum on the table.46 Right hip flexion with the knee extended was measured as 60 degrees compared with 90 degrees on the left. Piriformis muscle length was estimated by adducting and medially rotating the femur toward the midline with the hip flexed 90 degrees. The pelvis was stabilized, and the opposite lower extremity was extended.46 The right femur could not be adducted to the patient's midline because of pain compared with the left femur adducting considerably past midline. The Thomas test was used to examine iliopsoas and rectus femoris muscle length.46 The right iliopsoas muscle length was measured as -30 degrees from neutral hip extension, and the rectus femoris muscle length was measured as 60 degrees of knee flexion. The left iliopsoas muscle length was measured as 0 degrees (neutral) of hip extension, and the rectus femoris muscle length was measured as 90 degrees of knee flexion. The Ober test to assess for tensor fasciae latae muscle and iliotibial band tightness was not tolerated because of the patient's complaints of pain when the right hip was brought into extension during the test.46
Passive Mobility Testing
The patient had decreased posterior rotation of the right innominate as tested in left side lying.2,32 Passive testing revealed grade 1/6 hypomobility on the right compared with grade 3/6 mobility (normal) on the left. The grading of passive mobility was on a scale of 0 to 6, as described by Paris and Loubert.26 Ilial anterior rotation of the right innominate also was tested, but the patient reported a significant increase in pain with a few degrees of hip extension, and the test was stopped.2,32 The patient had full hip extension on the left, with grade 3/6 passive mobility for ilial anterior rotation. No studies have investigated the passive accessory movements of the SIJ. Inflare and outflare, anterior and posterior translation, and sacral flexion and extension were not tested due to increased tissue tenderness in this region.2,32
Palpation for Tenderness
Increased temperature was palpated over the right posterior sacroiliac region, with increased tissue tenderness. Tenderness was noted over the right long dorsal sacroiliac ligament (LDL) as palpated caudal to the PSIS.47 The LDL restrains anterior rotation of the ilium on the sacrum and has been reported to be painful on palpation 76% of the time in women diagnosed with ilial anterior rotation.47,48 Hypertonicity and tenderness also were palpated in the right piriformis, erector spinae, and iliopsoas (Baer's point) muscles as compared with the left.2 Baer's point is a landmark utilized to assess iliopsoas muscle tonicity and is palpated one third of the distance from the umbilicus to the ASIS.2
Special Tests
The patient had positive FABER, Ostgaard, and long-sit tests.32 The FABER test is performed with the patient positioned supine. The examiner flexes, abducts, and laterally rotates the involved leg until the foot rests on top of the knee of the noninvolved lower extremity. The examiner then contacts the knee on the involved side and slowly abducts the leg closer to the table. 49 The Ostgaard test is performed with the patient positioned supine with the painful hip flexed to 90 degrees. A downward force is applied through the femur to cause a posterior translation of the innominate on the sacrum as the opposite hand is placed under the sacrum to stabilize it.40 During the long-sit test, the patient lies supine with both hips and knee extended as the examiner stands with the thumbs on the patient's distal malleoli. The examiner passively flexes both knees and hips and then fully extends and compares the position of the medial malleoli relative to each other. The patient then slowly assumes the long-sitting position, and malleolar position is re-assessed.49 An Apparent Leg-Length Discrepancy Test also was performed, with the right leg measuring 1.25 cm longer than the left leg.49 Although there is some evidence to support the use of pain provocation tests to identify SIJ pain,18–21 no research has been performed investigating provocation tests and SIJD.
Manual Muscle Tests
Manual muscle tests were not performed due to the patient's pain.
| Evaluation |
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TopAbstractIntroductionPatient History/Review of...ExaminationEvaluationInterventionOutcomesDiscussionConclusionReferences |
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Diagnosis
Following the Guide to Physical Therapist Practice,30 the patient's Preferred Physical Therapist Practice Pattern was Musculoskeletal Pattern D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction.
Prognosis
The patient's acute onset of pain occurred 2 days prior to her first physical therapy visit, and the examination could not be completed because of pain. Her pain level did not seem disproportionate to the dysfunction. Although not all of the tests and measures could be completed during the examination, adequate information was collected to identify the dysfunction and obtain a prognosis. There was some degree of uncertainty as to whether the patient would return to her #3 singles position on her tennis team, because the injury appeared to be directly related to her tennis stroke. Modifications would have to be made in her 2-handed backstroke to limit the repetitive anterior rotational forces that caused her injury. It was not known to what extent modifying her tennis stroke would affect her tennis performance. The patient decided to miss the fall tennis season but would have 24 weeks to rehabilitate in preparation for the conference season in the spring. The likelihood of a female collegiate tennis player with SIJD returning to competition has not been reported in the literature.
The short-term goals of intervention were: (1) to decrease tissue tenderness of the right SIJ region (1–2 weeks); (2) to restore pelvic, lower-extremity, and trunk joint mobility and tissue flexibility comparable to the left side (6–8 weeks); and (3) to progress to stabilization (9–10 weeks), aerobic conditioning (11–14 weeks), and agility exercises (15–20 weeks). The long-term goal of the patient was to return to competitive tennis at the collegiate level by the spring season (24 weeks).
| Intervention |
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By the fourth visit, decreased warmth and tenderness were noted on palpation in the SIJ region. The patient reported pain of 3 out of 10 while sitting, standing, and walking and pain of 1 out of 10 while lying on her left side. The TENS and ice and were discontinued, and ultrasound (US) treatment began. Pulsed (50%) US (Excel EX-UL2 stimulator)
was applied for 5 minutes over the right posterior SIJ ligaments at an intensity of 0.8 W/cm2 at a 1-MHz setting. Pulsed US was used to aid in the healing process.55–58 Effleurage and petrissage massage techniques were continued to decrease tonicity in the right lumbar erector spinae and piriformis musculature with the patient in the prone position.54 Because the tissue tenderness of the SIJ was low and muscle guarding was reduced, the patient was instructed in a muscle energy technique that included a submaximal simultaneous isometric contraction of the right gluteus maximus and left iliopsoas muscles.2,32,39 Muscle energy is defined as the use of an active muscle contraction from a precisely controlled position, in a specific direction against a distinctly executed counterforce capable of restoring anatomical relations.38 The patient also was instructed in a kneeling/lunge exercise (right hip flexed and left hip extended) to promote right posterior ilial rotation.2,39 The purpose of the muscle energy and kneeling/lunge exercises was to promote self-correction of the right anterior ilial rotation hypermobility dysfunction. Each exercise was performed 5 times in the clinic, and the patient was instructed to perform the exercises every 2 hours for 5 repetitions while awake at home. She discontinued icing at home and continued with the positioning techniques while avoiding sitting, standing, and walking for longer than 30 minutes.
On the fifth treatment visit, pelvic position, active and passive mobility of the right innominate, and leg length were reexamined. The findings continued to correlate with a right anterior ilial rotation dysfunction. Treatment was progressed to include SIJ manipulation to correct the dysfunction. A change in innominate rotation after SIJ manipulation has been reported in the literature.59 Right posterior ilial rotation grade III sustained manipulation was performed 3 times with the patient in a side-lying position.2,32,39
Improved passive and active posterior rotation of the right innominate were observed after treatment. Pulsed US was performed after the manipulation at the same treatment settings as the previous treatment. The patient was instructed to continue with her home exercise program (HEP).
Upon returning for the sixth treatment, the patient was reexamined for pelvic position, leg length, and active and passive mobility of the right innominate. She continued to exhibit an increased inclination angle and decreased posterior rotation of the right innominate, with a functional leg-length discrepancy. Posterior ilial rotation manipulation was performed as during the previous treatment in an attempt to correct the positional fault. Brief reexamination after the manipulation revealed that pelvic position and posterior ilial rotation of the right innominate were comparable to the left innominate, and leg lengths also were now equal. Passive mobility testing revealed significant hypermobility (grade 5) for right ilial anterior rotation. Passive accessory motion of the SIJ has not been investigated, but Gonnella et al60 have reported high intrarater reliability when evaluating passive intervertebral motion. Pulsed US again was performed over the right posterior SIJ ligaments. A sacroiliac belt and pad
was placed on the patient while positioned supine after she performed the isometric manipulation exercises because external stabilization was needed to help maintain pelvic position. Sacroiliac belts have been reported to decrease significant SIJ rotation.61 The patient was instructed to wear the sacroliac belt throughout the day unless she was lying down or in the shower. She continued with her HEP.
On the seventh treatment visit, the patient reported pain of 0 out of 10 when sitting, standing, or lying down and pain of 2 out of 10 when walking. Range-of-motion and length tests of the trunk and right lower extremity were reexamined. Range-of-motion measurements and tissue lengths improved as a result of decreased pain and muscle guarding and correction of the positional fault. Intratester reliability is high when the same tester documents increases in joint motion of at least 3 to 4 degrees.62 Gadjdosik and Lusin63 have reported intratester reliability (Pearson r) of .99 when testing hamstring muscle tightness. A positive Ober test was a significant finding because tightness can create ilial anterior rotational forces.2 The patient continued with impairments related to soft tissue tightness and SIJ hypermobility.
Stretching techniques that were perceived as moderate in intensity as described by the patient were initiated. Soft tissue passive stretching included: (1) hip adductors with the patient positioned supine, stabilizing the iliac crest and keeping the femur in neutral rotation; (2) iliopsoas and rectus femoris muscles in the Thomas test position, stabilizing the right iliac crest in posterior rotation; (3) straight leg raise for the hamstring muscles with the patient positioned supine and the opposite hip and knee flexed; (4) piriformis muscle with patient positioned supine and the left lower extremity extended, adducting and medially rotating the femur toward the opposite shoulder; and (5) standing iliotibial band stretch with the right hip in slight extension, neutral rotation, and adduction. The patient was instructed to perform a home version of the flexibility exercises, 5 to 10 repetitions each, utilizing the left side as a comparison for normal tissue length. She was to continue with the muscle energy and kneeling/lunging positional exercises for posterior ilial rotation 3 to 5 times per day. The sacroiliac belt was to be worn at all times during the day, except when lying down, standing in the shower, or performing her HEP.
At the eighth treatment visit, the patient reported pain of 0 out of 10 with walking. She was reexamined for innominate position, leg length, and active and passive posterior ilial rotation mobility. Passive sacral flexion and extension, ilial anterior and posterior translation, and pelvic inflare and outflare were assessed for the first time.2 Innominate position and leg length on the right side were comparable to the left side, and no mobility impairments were identified. Stretching was performed, as during the seventh visit, until normal tissue lengths were achieved on the right side as compared with the left side. Normal mobility and tissue length were achieved prior to initiating a stabilization program because muscles can generate more force when they are at their optimal length. The patient was instructed in a beginning-level stabilization program. Stabilization exercises have been reported to increase sacroiliac stability and functional outcomes in patients with low back pain and SIJD.64–66 The initial program emphasized the transversus abdominis, lower rectus abdominis, gluteus maximus, internal and external oblique, and multifidus musculature. The above stabilization exercises were added to her current HEP and performed one time per day, one set to fatigue. The goal was to increase muscular endurance by progressing each exercise to 20 repetitions.
The patient continued with the same treatment regimen over the next 3 weeks, returning 2 times per week for reassessment and progression of her stabilization program. She was adherent to her HEP and progressed to an advanced stabilization program. Exercises included targeting the contralateral gluteus maximus, latissimus dorsi, iliopsoas, and gluteus medius and minimus muscles and the external rotators of the hip. The patient demonstrated an improved ability to stabilize the right innominate, and the sacroiliac belt was discontinued during normal daily activities at the end of the sixth week.
Starting in the seventh week, the patient's treatment frequency was reduced to 1 time per week for reassessment and progression of her HEP. She began aerobic conditioning with the sacroiliac belt for 20 to 30 minutes every other day, which consisted of 15 minutes of stationary bicycling and 5 to 10 minutes of stair-climber exercise. Over the next 2 weeks, the duration of the aerobic conditioning was gradually progressed to 45 minutes (30 minutes of stationary bicycling and 15 minutes of stair-climber exercise). During this time, the patient was monitored closely for inflammation, pelvic position, leg length, and posterior ilial rotation mobility. Cardiovascular fitness improved, and the tissue tenderness of the right SIJ structures remained low. A walking-jogging program was initiated at the beginning of the eighth week. The patient began walking for 10 minutes, followed by jogging at a slow pace for 10 minutes, and ending with another 10-minute walk on an indoor track. She performed this program every other day as she continued her 45-minute routine with the stationary bicycle and stair climber on alternate days. On the ninth week, the program was progressed to 15 minutes of jogging while continuing a 10-minute warm-up and cool-down. The same progression continued, adding 5 minutes of jogging time until the patient was jogging 30 minutes by the end of the 12th week.
The patient began agility exercises on the 13th week, starting with lateral shuffles and jogging backward. The agility exercises were performed on alternate days of the walking-jogging program, and the stationary bicycle and stair climber were discontinued. Initially, the patient began with 10 minutes of agility exercises, but progressed to 20 minutes by the 15th week. Additional agility exercises were added during this time, consisting of carioca, plyometrics off a 10.16-cm (4-in) box, and half-paced 18.3-m (20-yd) jogging stop and go. The patient also began a weight-bearing eccentric hamstring muscle exercise that involved sliding her feet forward on a slick surface. The biceps femoris muscle has an anatomical connection with the sacrotuberous ligament. Strengthening the hamstring muscles could increase force closure and increase stability of the SIJ.2 Sprinting 36.6 m (40 yd) at the end of the walking-jogging program was performed 4 times at the start of the 16th week.
A videotape of the patient playing a tennis match was obtained and analyzed during the 16th week. She was observed to hit every backhand with 2 hands, producing a significant amount of right anterior ilial rotation as she pivoted on her right foot with the leg in extension. She also was noted to hit twice as many backhands as she did forehands. The patient's 2-handed backhand stroke was modified so that the right leg came off the ground instead of being firmly planted behind her on the follow-through. She was instructed to position herself on the court to hit more forehand strokes and fewer backhand strokes. The patient began hitting her various tennis strokes, excluding her 2-handed backhand stroke. She was instructed to practice her strokes and move around the court at one third of her normal speed and intensity for 15 minutes.
At the start of the 17th week, the patient was instructed to increase her practice time to 30 minutes while continuing to wear her sacroiliac belt. She also began hitting her modified 2-handed backhand stroke with one third of her normal speed and intensity. The patient was responding well, with no signs of tissue strain. During the 18th and 19th weeks, the patient was instructed to increase her playing speed and intensity to 50% of her capacity and to increase her practice duration to 45 minutes. She continued to progress well during this period, with no signs of tissue strain, progressed to playing 75% of her normal speed and intensity the by 20th week of her rehabilitation. The patient was reexamined at the end of the 20th week because of complaints of soreness in the right sacral sulcus region. Reexamination revealed increased tenderness of the LDL with palpation. Minimal inflammation was noted, with an increased temperature change of the right SIJ region. The patient's pelvic position, leg length, and active posterior ilial rotation remained normal compared with the left side. She was instructed to ice the region and to take the weekend off and return the following Monday for reexamination.
The patient returned the following week, and the inflammation and tenderness had subsided. No impairments were found on reexamination. She was instructed to resume practicing tennis but to reduce the speed and intensity to 50%. The patient continued this course of care for 2 weeks, without complaints of tenderness or pain. On the 23rd week, the patient was instructed to increase her speed and intensity to 75% of her capacity on the tennis court.
Within 3 days, the inflammation and pain again developed in the right sacral SIJ region. The patient was becoming very anxious about her ability to return to competitive tennis, as the spring season was approaching. She was instructed to discontinue practice for 2 days to rest and ice. The patient responded well, and the inflammation and tissue tenderness quickly subsided. With the continued flare-ups, it was decided that proprioceptive taping might benefit the patient because it would stimulate the gluteus maximus muscle and support the LDL. Positive outcomes have been reported with proprioceptive taping in patients with patellofemoral pain syndrome.67–77 Before practice, the patient was positioned in left side lying with the right hip flexed to 45 degrees and the femur supported in neutral rotation. The right hip was flexed to position the right ilium in slight posterior rotation. Two strips of 5.08-cm (2-in) Cover Roll
were placed over the right iliac crest covering the ASIS and PSIS. Two pieces of 5.08-cm (2-in) Leukotape were firmly applied from the ASIS to PSIS in an anterior- to-posterior direction. The first piece of tape was applied to restrain anterior ilial translation and was pulled in a straight anterior-to-posterior direction (Fig. 1); the second piece of tape was applied to restrain anterior ilial rotation and was a pulled along the iliac crest in an arcing manner (Fig. 2).
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Anatomical and hormonal differences also may have predisposed the patient toward developing a hypermobility dysfunction. Anatomically, females have less stability through the interlocking components of the SIJ compared with males. The joint surfaces between the sacrum and ilium are relatively smoother and smaller in females than in males.78 The width of the upper facet occupies a third of the sacrum in females, whereas the upper facet in males occupies nearly one half of the sacrum.78 Additionally, the joint surface in females extends only down to the upper border of the third sacral segment compared to the lower border of the third sacral segment in a males.78 The hormones estrogen, progesterone, and relaxin fluctuate during the menstrual cycle.79 There are conflicting research data on the effects of female hormones on ligament laxity. Although previous studies79,80 showed a significant difference in anterior cruciate ligament laxity with increased levels of estrogen and progesterone, more-recent investigations81–85 did not demonstrate a relationship between ligament laxity and hormonal changes during the menstrual cycle. The effects of hormonal changes on musculotendinous stiffness also have been investigated. Eiling et al83 reported a significant decrease in musculotendinous stiffness as female hormones increased during menstruation. Although it was not known whether our patient's injury correlated with her menstrual cycle, a decrease in musculotendinous stiffness could have been related to the mechanism of injury.
Hypertonicity and tenderness were palpated in the patient's myofascial structures that supported her SIJ. Decreased stability of the SIJ causes a greater reflexive response of the contractile components.83 Increased electromyographic activity of the gluteus maximus muscle has been reported in patients with SIJ pain.86 The long head of the biceps femoris muscle and the gluteus maximus and piriformis muscles have anatomical connections with the sacrotuberous ligament and often exhibit hypertonicity on the same side of the SIJ pain.2,87,88 Contraction of these muscles causes tension on the sacrotuberous ligament and provides support to the SIJ.2 The psoas and quadratus lumborum muscles also provide stability to the SIJ and often are tender and hypertonic in patients with SIJD.2
The patient reported increased stability in the SIJ when she used proprioceptive taping. The mechanical properties and proprioceptive role of the sacroiliac ligaments are unknown. Proprioceptive taping has not been investigated with SIJD, but it has been reported to increase joint stability when applied to impaired joints.67–73 The mechanism by which taping increases joint stability is controversial. Taping of the SIJ may aid in sacroiliac function for the same proposed reasons that patellar taping positively affects patients with patellofemoral pain syndrome. Taping may affect the function of the SIJ by reducing pain or improving proprioceptive feedback, neuromotor control, or sacroiliac alignment, or a combination of these factors.67–77 The patient also reported increased stability of the SIJ when wearing a sacroiliac belt. A sacroiliac belt provides compression and proprioceptive feedback to the gluteal muscles and has been reported to reduce SIJ rotation.61 External stabilization was needed for this patient to help maintain pelvic position. Future research regarding the proprioceptive role of the SIJ ligaments and the effects of taping on SIJ stability is needed.
Extensive research investigating the myofasical structures that affect SIJ stability has been conducted. Exercises that targeted the patient's transversus abdominis and multifidus musculature were initiated early in her rehabilitation program. Exercise techniques that promote independent contraction of the transversus abdominis and multifidus muscles have been reported to lower reoccurrence rates in patients with acute low back pain, to lower pain and disability in patients with chronic low back pain, and to reduce laxity in the SIJ.64–66 The posterior layer of the thoracolumbar fascia also plays an important role in stabilizing the lower lumbar spine and SIJ.89 Muscles attaching to the posterior layer assist in transferring the load among the spine, pelvis, legs, and arms.89,90 The delayed onset of obliquus internus abdominis, multifidus, and gluteus maximus muscle activity has been reported in patients with sacroiliac pain.91 The patient was instructed in specific exercises to coordinate and strengthen the gluteus maximus, internal and external oblique, and latissimus dorsi musculature to increase force closure and SIJ stability through their attachments to the thoracolumbar fascia.
| Conclusion |
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TopAbstractIntroductionPatient History/Review of...ExaminationEvaluationInterventionOutcomesDiscussionConclusionReferences |
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After 26 weeks (33 treatments), tissue tenderness of the SIJ region was normalized, pelvic/trunk and lower-extremity mobility and flexibility were restored, and sacroiliac symmetry and stability were regained, and the patient achieved her long-term goal of returning to competitive tennis at the collegiate level.
| Footnotes |
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This case report was completed in partial fulfillment of the requirements for Dr Vaughn's Doctor of Physical Therapy degree at the University of St Augustine for Health Sciences.
* Empi, 599 Cardigan Rd, St Paul, MN 55126-4099. 
Excel Tech LTD, 2892 Portland Dr, Oakville, Ontario, Canada L6H 5W8.
Saunders Group, 4250 Norex Dr, Chaska, MN 55318-3047.
Beierdorf-Jobst Inc, 500 Fillmore Ave, Rutherford College, NC 28671.
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TopAbstractIntroductionPatient History/Review of...ExaminationEvaluationInterventionOutcomesDiscussionConclusionReferences |
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  D. C Poulter On "Ilial anterior rotation..." Vaughn HT, Nitsch W. Phys Ther. 2008;88:1578-1590. Physical Therapy, May 1, 2009; 89(5): 507 - 508. [Full Text] [PDF]
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M. T Cibulka On "Ilial anterior rotation..." Vaughn HT, Nitsch W. Phys Ther. 2008;88:1578-1590. Physical Therapy, May 1, 2009; 89(5): 508 - 509. [Full Text] [PDF]
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J. Hesch On "Ilial anterior rotation..." Vaughn HT, Nitsch W. Phys Ther. 2008;88:1578-1590. Physical Therapy, May 1, 2009; 89(5): 509 - 511. [Full Text] [PDF]
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H T. Vaughn Author Response Physical Therapy, May 1, 2009; 89(5): 511 - 512. [Full Text] [PDF]
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