Women walk into CTS sometimes looking like ET, with a short stride gait and tipping their body to the right and left to allow their leg to swing forward to walk. ET may be a funny image but Sacro-Iliac (SI) and Pelvic Girdle (PG) pain are no laughing matter; they can affect the ability to safely transfer loads through the pelvis for simple things like getting in and out of bed, walking, lunging, and stair climbing. The front, center joint of the pelvis, termed symphysis pubis, may be involved as well with a separation or loosening. No fun.

SI and PG pain limit sex too! Our pelvic PT evaluation screens for SI and PG problems with medically validated tests that are critical for individualized exercise prescriptions. Associated low back pain, bladder, bowel problems, sexual dysfunction, and diastasis rectus abdominus may be present. There is no cookbook or one size fits all workout. New clients are often surprised at how much we "find" during our evaluations. Here are some facts for you:

• Risk factors for SI and PG pain include; prior injury to those areas, hormone disruptions associated with pregnancy and birth, birth "trauma" from overstretch and strain around these joints, multiple pregnancies, and frequent lifting. Genetics may play a role as well with "hypermobility syndrome" and other conditions associated with disuse and weakening of muscles and connective tissue. The front joint, symphysis pubis, may be involved as well, with a separation or loosening.


• Selective stabilization exercises are the best treatment according to research guidelines.


• Use of SI belts, binders, and corsets may help. Kinesiotape may help.


• Severe post partum cases may briefly need a wheelchair or walker.


• Male SI and PG pain may occur in association with trauma, surgery, or genetic factors, however these conditions are more common in females.

Stabilization exercises often take months, or in long-term cases, a year or more to work to the point of "feeling powered up" for hills and stairs. This is because many muscle systems are involved and postural and exercise habits that are harmful must be detected and stopped. If one performs with moderate to maximal exertion with an "unstable system" the muscles will lock up, cramp, and hold to protect from further strain. So the exercises often start with low reps, low exertion, and build once every 2 weeks. Before exercise can be safely performed, postural symmetry must be obtained, as there is often a rotation of one side of the pelvis or the tailbone (sacrum) in one plane. There can also be a vertical displacement up or down of an involved segment. Manual therapy is used to re-align segments and exercise, posture and habit programs assist in re setting the pelvis in a symmetrical fashion. (In severe cases, surgical fixation is advised, yet optimally the body is maximally strengthened, balanced, and trained to optimize performance post op. Surgery will not fix multi system weakness, only tighten one joint region. And as you delve back into medical histories, multiple injuries or pregnancies are noted to be associated with a reduction of function in overall strength. So many conditions of SI and PGP are years in the making.) Most clients we see may have an onset of pain during pregnancy or postpartum, or have been in a car accident with one foot "slamming on the brake" or had a significant fall onto the pelvis. Think of falls with snowboarding, skateboarding, gymnastics, basketball, or volleyball.

Here is a posterior view of the SI joint, and the pelvic girdle (PG). PG pain is that which occurs from the crest of the ilium into the lower gluteal region. SI and PG pain may exist by themselves or co-exist with back, hip, groin, and perineal pain.

References:
European guidelines for the Evaluation and Treatment of Pelvic Girdle Pain The primary objective of this guideline is to provide a set of recommendations that can support future national and international guidelines on PGP. Ultimately, this should lead to the prevention of long-term complications, reduction of pain, and improvement of disability. Vleming, Alber et al: European Spine J (2008) 17:794-819

Integrating Exercise Is Medicine into the Care of Pregnant Women Joy, Mottola, Current Sports Medicine Reports American College of Sports Medicine Volume 12: 4 2013

Sacroiliac Joint Pain Diagnosis, The Past and the Future: Orthopedic Physical Therapy Practice, Tomas, Andrew, 25:4, 2013

By Maureen Mason, MS PT WCS, CCI, PYT-C

Personal note: Maureen's adventure with SI and PGP

I am fascinated with this topic as I suffered through a loss of function with associated SI and PGP in my 30's after childbirth, and became resigned that that was the new me, unable to lift without pain, walk up hills without hips cramping, and I was unable to sleep on my left side. In retrospect in my 20's I was running down Mt Cuyamaca and fell really hard on one hip, and felt out of alignment after that; I had a classic "up-slip" on the side I landed on. Postpartum with a 4 yr old and 1yr old: I finally had a few evaluations from different therapists (there were no pelvic PT specialists back then!) I put myself on a program and have continued ever since, and I enjoy a high level of function. But honestly I thought it was ridiculous how long it took me, over a year, to feel powerful walking up a hill, and pain-free!

In January I wrote a note discussing my plans for the upcoming year and increasing physical activity while being outdoors. I asked each person to challenge themselves and work towards big goals through small changes. On Tuesday July 19th I had the opportunity to hike Mt. Whitney. The vistas and changes in terrain were some of the most dramatic views I have ever seen. I was able to hike slowly to the top of the highest mountain in the lower continental United States one step at a time with a little help from my friends.

Looking back on the small goals that got me to Mt. Whitney, it was the weekly preparation from early January until July that made all the difference. I have hiked almost every weekend since January with varying difficulty and length. In January I hiked an average of three to five miles on Saturdays. In the last two months I have hiked an average of ten to 15 miles on a Saturday. I have completed the five peak challenge in San Diego, hiked Le Cajon mountain, climbed three of the six peaks in San Bernardino, hiked in Mt. Laguna, Inyo National Forest, Joshua Tree National Park, Anzo Borrego State Park, Yosemite National Park, and smaller trails right here in San Diego. So much of the hiking has been done with family and friends of all different fitness levels. I even hiked with my sister who could only walk on flat ground five weeks after her knee surgery. The only reason I share these experiences is to invite others to start at the beginning. Dream big and then take the little steps needed to get there.

I often have patients who are intimidated by large goals for their health, and it keeps them from starting. As physical therapists at Comprehensive Therapy Services, we understand how intimidating changing your pain levels or activity level may be. So many of our therapists have their own history of sports injuries, pelvic floor pain, weakness after childbirth, sciatica, neurological disorders, and so on. No one has been left out of struggles with our body. However, since we have our own past and present with health struggles, we want to help each of you on the journey towards greater mobility and a healthier lifestyle. We often start you with very simple breathing exercises, small range of motion movements, and core strengthening exercises. This is because we understand how important building a strong foundation is for your long term recovery. Working on the simple tasks, although boring, is the only way to work towards resolving pain versus masking pain for a short period of time.

It is our goal to explain why you are performing the exercises prescribed by your therapist. Every once in a while I will have a patient who wants to do high intensity exercise without being able to maintain core stability. My job as a physical therapist is to give you the foundation. Then you can then go back into the community and work towards your "Mt. Whitney" type fitness goals without fear of starting back at the beginning. This type of change requires commitment to the basics and a decision to keep doing the simple exercises that keep your pain away (or down) so you can reach higher levels instead of repeating the same injuries over and over. Please remember that breathing is the starting place for a strong core. If you are not in control of your breath, your core will often work against you instead of for you. If your core is weak, you can have pain in your spinal, shoulders, hips, knees, ankles, and pelvis. With this in mind, please see your home exercise program as a set of vitamins you take each day to keep your pain away. As you strengthen your pain will decrease and your mobility will increase.

As I write I am looking forward to making my next "Mt. Whitney" goal. Each time I achieve a big fitness goal I am reminded of how much I can do if I will take the time to train regularly. My challenge for the second half of the year is the same as the first half. Please remember,
"What doesn't challenge you doesn't change you!"

By Kira Shurtz, PT

creating power through movement

 heal. nurture. educate. inspire. energize. respect.