Screening the Sacrum, Sacroiliac, and Pelvis

Following the model for decision making in the screening process outlined in Chapter 1 (see Box 1-7), we now turn our attention to pain from medical conditions, illnesses, and diseases referred to the sacrum, sacroiliac (SI), and pelvic regions.

The basic premise is that physical therapists must be able to identify signs and symptoms of systemic origin or associated with medical conditions that can mimic neuromuscular or musculoskeletal (neuromusculoskeletal [NMS]) impairment in these areas.

In the screening process, therapists will watch for yellow (caution) or red (warning) flags to direct them. Clinicians rely on special questions to ask men and women with significant risk factors, significant past medical history, suspicious clinical presentation, or associated signs and symptoms.

With a careful interview and the right screening questions, the therapist can identify clues suggestive of a problem outside the scope of a physical therapist’s practice that may require medical referral. Specific tests to screen for an underlying infectious or inflammatory source of pelvic or abdominal pain are also presented with a suggested order of testing.

When dealing with painful symptoms of the sacral and pelvic areas, the therapist may need to ask questions about sexual history or sexual practices. The therapist must remain aware of facial expressions, body language, and verbal remarks in response to a client’s answers to these questions.

The therapist must be prepared to respond in a professional and responsible way if a man or woman with pelvic or sacral pain reports that he or she has been the victim of repeated violent sexual acts, or if a client admits to physical or emotional assault. More about the client interview, the screening interview, and screening for assault and domestic (intimate partner) violence is included in Chapter 2 (see also Appendices B-3 and B-32).

The Sacrum and Sacroiliac Joint

Evaluating the SI joint can be difficult in that no single physical examination finding can predict a disorder of the SI joint. Pain originating from the SI joint can mimic pain referred from lumbar disk herniation, spinal stenosis, facet joint impairment, or even a disorder of the hip.1–3

The most common clinical presentation of sacroiliac pain is associated with a memorable physical event that initiated the pain such as a misstep off a curb, a fall on the hip or buttocks, lifting of a heavy object in a twisted position, or childbirth (Case Example 15-1). A history of previous spine surgery is very common in clients with SI intraarticular pain.¹

Case Example 15-1 Sacroiliac Pain Caused by Pelvic Floor Impairment

Background: A 33-year-old woman referred by her orthopedic surgeon presented with low back pain centered over the sacroiliac (SI) region. She described it as “sharp” and “knifelike.” It comes and goes with no warning. Sometimes, it is so severe she cannot catch her breath and falls to her knees. After that, she cannot stand up straight for several hours and walks “hunched over.”

The pain presented on both sides intermittently, but the primary pain pattern was localized in the left SI area. Heat seems to help for a short time, but nothing brings complete relief all the time.

She has a previous history of disk herniation with diskectomy and laminectomy and complete resolution of symptoms. No cause is known for this new onset of SI symptoms. No radiating symptoms are apparent, and recent magnetic resonance imaging (MRI) shows no sign of disk protrusion at this time. (She tried doing her previous program of McKenzie exercises, but no change in symptoms occurred.)

Clinical Presentation: Physical therapy examination reveals the following:

Antalgic gait secondary to pain. Trendelenburg sign: Negative. Slight left lumbar lateral shift; posture within normal limits otherwise. Active lumbar motions are full, with a normal capsular end feel and no reproduction of symptoms. Repeated trunk and lumbar motions do not elicit painful symptoms.

Neurologic screen: Negative for abnormal reflexes, abnormal sensation, decreased strength, or altered neural tension. Hamstrings are tight bilaterally, but a straight leg raise does not increase symptoms. In fact, it is the only time in the assessment when the client reports a slight decrease in pain.

Examination of the SI area revealed an upslip on the left (anterior superior iliac spine [ASIS] and posterior superior iliac spine [PSIS] on the left are higher than ASIS and PSIS on the right, indicating an upward movement of the ilium on the sacrum on the high side; leg length discrepancy or muscle spasm from a disk lesion can also cause an upslip). Given her past history of diskogenic lesion, it is possible that altered muscle activation is the cause. This will have to be examined further.

Is a screening examination for systemic origin of symptoms warranted? Why, or why not?

Using our screening model, review the past medical history. Are there any red flags here? No, but the history is very incomplete. We know she had a previous diskogenic lesion treated operatively. Nothing of her personal or family history is included.

Even in a musculoskeletal assessment, we will want to know about pregnancy and birth histories; use of medications, over-the-counter drugs, and illicit drugs; smoking and drinking history or current use; levels of activity before the onset of symptoms; correlation of symptoms with menses or births; occupation and work-related activities; and history of cancer.

A general screening interview will ask about recent history of infection, the presence of joint pain or skin rash anywhere else, and the presence of any constitutional or other symptoms.

Next, review the clinical presentation. Are there any red flags here? Not really. There is no night pain. There is the fact that nothing seems to make it better or worse, but one red flag by itself usually is not highly significant. We will tuck that bit of information in the back of our minds as we continue the evaluation process.

Hamstring stretching brings some mild, temporary relief. This suggests a muscular component, but that has to be further evaluated. The SI upslip could be the cause of the symptoms, but this will not be determined until the alignment and cause of the upslip are corrected.

A trigger point assessment may be needed as well.

Step three involves a review of associated signs and symptoms. We do not know about constitutional symptoms, relationship of SI pain to menses, or the presence of any other symptoms associated with the viscera (e.g., gastrointestinal, urologic). It is always recommended to take the client’s temperature in the presence of pain of unknown cause.

What to Do: Several strategies are presented here. Intervention for the upslip may be the first step with reassessment of symptoms. If a lack of progress occurs, the therapist can go back and ask more specific questions. Or, the therapist can treat the upslip while continuing to interview the client each day, obtaining additional pertinent information before making a final decision.

Result: In the end, it was discovered that the client had significant pelvic floor impairment with overactivity of the pelvic floor muscles (levator ani) and detrusor imbalance with urinary incontinence. She reported a complicated birth history with her first child, which was repeated with less severity during the births of her second and third children.

Intercourse was extremely painful, but the client was too embarrassed to bring this up until the therapist asked directly about sexual activity. The client finally described a sensation as if “trying to deliver a baby through my rectum” during intercourse (a sign of levator ani impairment).

Once all the additional information had been brought out and organized, the client shared the signs and symptoms with her gynecologist. An internal vaginal examination reproduced her symptoms exactly. The evaluating therapist was not trained in pelvic floor assessment and did not make this finding directly.

In looking back, it is likely that development of the diskogenic lesion was linked to birth/delivery problems (or perhaps, vice versa; it was never known for sure). Closer examination revealed a loss of lumbar stabilization because of multifidus impairment. Muscle impairment at the time of the disk lesion and births probably contributed to the gradual development of pelvic floor impairment.

Changes were also noted in the abdominal muscles with a loss of co-contraction between the multifidus and the transversus abdominis. The levator ani and pelvic floor muscles were in a contract-hold pattern, contributing to the painful symptoms described.

Heat relaxed the muscles but only for a short time. Hamstring stretching may have brought about an inhibition to the pelvic floor muscles, reducing pain.

A program directed at restoring normal muscle tone and function in the lumbar spine, abdominal muscles, and pelvic floor resulted in immediate reduction and eventual elimination of painful symptoms and return of comfortable coitus. Symptoms of urinary incontinence also were resolved.

Although the SI upslip could be corrected, the client could not maintain the correction. Because she was pain free, she did not return to physical therapy for further evaluation of the underlying biomechanics around the SI upslip.

The most typical medical conditions that refer pain to the sacrum and SI joint include endocarditis, prostate cancer or other neoplasm,⁴ gynecologic disorders, rheumatic diseases that target the SI area (e.g., spondyloarthropathies such as ankylosing spondylitis, Reiter’s syndrome, or psoriatic arthritis), and Paget’s disease (Table 15-1).⁵

TABLE 15-1

Causes of Sacral and Sacroiliac Pain

IBD, Inflammatory bowel disease; SI, sacroiliac; PID, pelvic inflammatory disease; IBS, irritable bowel syndrome.

^*Includes benign and malignant osseous and neurogenic tumors affecting the sacrum.

Disorders of the large intestine and colon, such as ulcerative colitis, Crohn’s disease (regional enteritis), carcinoma of the colon, and irritable bowel syndrome (IBS), can refer pain to the sacrum when abscess develops or when the rectum is stimulated.⁶ Likewise, primary SI problems can refer pain to the lower abdomen.⁷

A medical differential diagnosis may be needed to exclude fracture, infection, or tumor. Insufficiency fractures of the sacrum can occur after pelvic radiotherapy for cancer ⁸ and in osteoporotic bone with minimal or unremembered trauma.⁹ (See further discussion in this chapter on spondylogenic causes of sacral pain.)

Using the Screening Model to Evaluate Sacral/Sacroiliac Symptoms

The principles guiding evaluation of SI joint or sacral pain are consistent with the information presented throughout this text and, in particular, in the chapter on back pain (see Chapter 14).

Each of the disorders listed in Table 15-1 usually has its own unique clinical presentation with clues available in the past medical history. The presence of associated signs and symptoms is always a red flag. Most of these conditions have clear red flag clues that come to light if the client is interviewed carefully.

Clinical Presentation

Insidious onset or unknown cause is always a red flag. Without a clear cause, the therapist looks for something else in the history or accompanying signs and symptoms. Even with a known or assigned cause, it is important to keep other possibilities in mind and to watch for red flags (Box 15-1). Sacral pain in the absence of a history of trauma or overuse is a clue to the presentation of systemic backache.

Box 15-1 Red Flags Associated with Sacroiliac/Sacral Pain or Symptoms

History

• Sacroiliac/sacral pain without a history of trauma or overuse (rule out assault, anal intercourse)

• Previous history of cancer

• Previous history of gastrointestinal (GI) disease (ulcerative colitis, Crohn’s disease, irritable bowel syndrome)

• Previous history of infection (skin, genitourinary tract, heart, septic sacroiliitis)

Risk Factors

• Osteoporosis

• Sexually transmitted infection or other organ system infection

• Intravenous drug abuse

• Long-term use of antibiotics (colitis)

Clinical Presentation

• Insidious onset/unknown cause

• Lack of objective findings

• Anterior pelvic, suprapubic, or low abdominal pain at the same level as the sacrum

Associated Signs and Symptoms

• Pain relieved by passing gas or having a bowel movement

• Presence of GI, gynecologic, or urologic signs and symptoms

• Fever (septic sacroiliitis); other constitutional symptoms

The amount and direction of pain radiation can offer helpful clues. Low back or sacral pain radiating around the flank suggests the renal or urologic system. In such cases, the therapist should ask questions about bladder or urologic function.

Low back or sacral pain radiating to the buttock or legs may be vascular. Questions about the effects of activity on symptoms and history of cardiovascular or peripheral vascular diseases are important (see discussion in Chapter 14). Sorting out pain of a vascular versus neurogenic cause is also discussed in Chapter 14.

Most commonly, unless pain causes muscle spasm, splinting, and subsequent biomechanical changes, clients affected by systemic, medical, or viscerogenic causes of sacral or SI pain demonstrate a remarkable lack of objective findings to implicate the SI joint or sacrum as the causative factor for the presenting symptoms. Pain elicited by pressing on the sacrum with the client in a prone position suggests sacroiliitis (inflammation of the SI joint) or mechanical derangement.

Sacroiliac Joint Pain Pattern: Whether from a mechanical or a systemic origin, the patient usually experiences pain over the posterior SI joint and buttock, with or without lower extremity pain. Pain may be unilateral or bilateral (Fig. 15-1)¹⁰ and can be referred to a wide referral zone, including the lumbar spine, abdomen, groin, thigh, foot, and ankle.^1,11

Fig. 15-1 Unilateral sacroiliac (SI) pain pattern. Pain coming from the sacroiliac joint is usually centered over the area of the posterior superior iliac spine (PSIS), with tenderness directly over the PSIS. Lower lumbar pain occurs in 72% of cases; it rarely presents as upper lumbar pain above L5 (6%). It may radiate over the buttocks (94%), down the posterior–lateral thigh (50%), and even past the knee to the ankle (14%) and lateral foot (8%). Paresthesias in the leg are not a typical feature of SI joint pain. The affected individual may report abdominal (2%), groin or pubic (14%), or anterior thigh pain (10%). Anterior symptoms may occur alone or in combination with posterior symptoms. Occasionally, a client will report bilateral pain. (Data from Slipman CW, Jackson HB, Lipetz JS, et al: Sacroiliac joint pain referral zones, Arch Phys Med Rehab 81:334-338, 2000.)

Clients with SI joint pain rarely have pain at or above the level of the L5 spinous process, although it is possible. The presence of midline lumbar pain tends to exclude the SI joint as a potential pain generator.12,13

A wide range of SI joint–referred pain patterns occur because innervation is highly variable and complex or because pain may be somatically referred, as discussed in Chapter 3. Adjacent structures, such as the piriformis muscle, sciatic nerve, and L5 nerve root, may be affected by intrinsic joint disease and can become active nociceptors. Pain referral patterns also may be dependent on the distinct location of injury within the SI joint.^13,14

SI pain can mimic diskogenic disease with radicular pain down the leg to the foot.¹⁵ People who report midline lumbar pain when they rise from a sitting position are likely to have diskogenic pain. Clients with unilateral pain below the level of the L5 spinous process and pain when they rise from sitting are likely to have a painful SI joint.^12,13

Pain from SI joint syndrome may be aggravated by sitting or lying on the affected side. Pain gets worse with prolonged driving or riding in a car, weight bearing on the affected side, the Valsalva maneuver, and trunk flexion with the legs straight.¹⁴

SI pain can also mimic the pain pattern of kidney disease with anterior thigh pain, but with SI impairment, no signs and symptoms (e.g., constitutional symptoms, bladder dysfunction) are associated, as would be the case with thigh pain referred from the renal system.

Screening for Infectious/Inflammatory Causes of Sacroiliac Pain

Joint infections spread hematogenously through the body and can affect the SI joint. Usually, the infection is unilateral and is caused by Pseudomonas aeruginosa, Staphylococcus aureus, Cryptococcus organisms, or Mycobacterium tuberculosis.

Risk factors for joint infection include trauma, endocarditis, intravenous drug use, and immunosuppression. Postoperative infection of any kind may not appear with any clinical signs or symptoms for weeks or months. Infections causing bacterial sacroiliitis as a complication of dilatation and curettage (D and C) after incomplete abortions have been reported.¹⁶

Infection can cause distention of the anterior joint capsule, irritating the lumbosacral nerve roots.¹⁷ Inflammation of the SI joint may result from metabolic, traumatic, or rheumatic causes. Sacroiliitis is present in all individuals with ankylosing spondylitis.¹⁸

Rheumatic Diseases as a Cause of Sacral or Sacroiliac Pain

The most common systemic causes of sacral pain are noninfected, inflammatory erosive rheumatic diseases that target the SI, including ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis, and arthritis associated with inflammatory bowel disease (IBD) such as regional enteritis (Crohn’s disease).

Reiter’s syndrome (see Chapter 12) occurs most often in young men with venereal disease. Reiter’s syndrome often presents as a triad of symptoms, including arthritis, conjunctivitis, and urethritis. These three symptoms in the presence of sacral pain raise a red flag. The therapist must ask about pain in other joints, urologic symptoms, and a recent (or current) history of conjunctivitis (red, painful inflammation of the eye).

A positive sexual history or known diagnosis of venereal disease is helpful information. With sacral or SI pain, the therapist should always consider taking a sexual history (see Special Questions to Ask in Chapter 14 or Appendix B-32).

Crohn’s disease (see Chapter 8) may be accompanied by skin rash and joint pain. This enteric condition is well known for its arthritic component, which is present in up to 25% of all cases. The client may have had Crohn’s disease for years and may not recognize the onset of these new symptoms as part of that condition. Skin rash may precede joint pain by days or weeks. The hips, thighs, and legs are affected most often; the rash may be raised or flat, purple or red. Knowing the history and association between skin lesions and joint pain can help the therapist direct screening questions and make a reasonable decision about referral.

Screening for Spondylogenic Causes of Sacral/Sacroiliac Pain

Metabolic bone disease (MBD) such as osteoporosis, Paget’s disease, and osteodystrophy can result in loss of bone mineral density and deformity or fracture of the sacrum. The therapist should review cases of sacral pain for the presence of risk factors for any of these metabolic bone diseases (see the discussion on metabolic bone disease in Chapter 11). Neoplasm and fracture are two other possible bony causes of sacral pain. Neoplasm is discussed separately in this chapter.

Metabolic Bone Disease

Mild-to-moderate MBD may occur with no visible signs. Advanced cases of MBD include constipation, anorexia, fractured bones, and deformity.

Osteoporosis: Osteoporosis can cause insufficiency fractures of the sacrum. The therapist must assess for risk factors (see Boxes 15-2 and 11-3) in anyone with sacral pain, especially those in whom pain has an unknown cause, postmenopausal women, older men (over 65), and anyone with a known history of osteoporosis or Paget’s disease. See further discussion on osteoporosis in Chapter 11 and discussion on fractures at the end of this section.

Box 15-2 Risk Factors for Sacral Fractures

• Osteoporosis (see also Box 11-3)

• Paget’s disease

• Gender (female)

• Athletes, military personnel (overuse, overtraining, improper footwear or training surface)

• Athletic pregnant or postpartum women

• Pelvic radiation

• Lumbosacral fusion (early postoperative)

• Osteomyelitis

• Multiple myeloma

• Trauma (motor vehicle accident, fall, assault)

• Prolonged use of corticosteroids

Paget’s Disease: Paget’s disease as a cause of lumbar, sacral, SI, or pelvic pain occurs most commonly in men over 70 years of age (although it can occur earlier and in women). It is the second most common metabolic bone disease after osteoporosis.

Characterized by slowly progressive enlargement and deformity of multiple bones, it is associated with unexplained acceleration of bone deposition and resorption. The bones become weak, spongy, and deformed. Redness and warmth may be noted over involved areas, and the most common symptom is bone pain (see further discussion on Paget’s disease in Chapter 11 and an excellent online article as referenced here).¹⁹

The therapist is more likely to see clients with referred low back or sacral pain from the small or large intestine as it presents in the low back or sacral area (see Figs. 8-15 and 8-16). Although these illustrations depict the pain in small, very round areas, actual pain patterns can vary quite a bit. The location will be approximately the same, but individual variation does occur.

The therapist must ask about the presence of abdominal pain or GI symptoms, occurring either simultaneously or alternating but at the same anatomic level as back or sacral pain. See Case Example 14-13 to review the importance of looking for this particular red flag.

Sacral pain from a GI source may be reduced or relieved after the person passes gas or completes a bowel movement. It may be appropriate to ask a client the following:

Follow-Up Questions

• Is your pain relieved by passing gas or having a bowel movement?

• The patient may have a history of GI disease and medication used to treat such a condition. Keep the following conditions or past histories in mind when asking questions of anyone with lumbar spine or sacral pain patterns:

• Ulcerative colitis

• Crohn’s disease

• Irritable bowel syndrome

• Colon cancer

• Long-term use of antibiotics (colitis)

Screening for Tumors as a Cause of Sacral/Sacroiliac Pain

Primary sacral tumors include benign and malignant growths. Benign neoplasms include osteochondroma, giant cell tumor, and osteoid osteoma. The more common primary malignant lesions directly affecting the sacrum include chordoma, chondrosarcoma, osteosarcoma, and myeloma.

MBD to the sacrum from primary breast, lung, colon, and prostate is far more common. Sacral insufficiency fractures after pelvic radiation for rectal, prostate, or reproductive cancers can occur, although these are rare.8,31

Although rare, sacral neoplasms usually are not diagnosed early in the disease course because of mild symptoms resembling low back, buttock, or leg pain (sciatica).32,33 Sacral tumors are not easy to see on x-rays and are easily overlooked due to the curvature of the sacrum, location deep within the pelvis, and frequent presence of overlying bowel gas. It is not uncommon for diagnostic delays as the person is treated for a presumed lumbar pathology before the sacrum is finally identified as the source of pathology.³³ Referral to a physical therapist before a correct medical diagnosis is made is not unusual.

Giant cell tumor is a highly aggressive local tumor of the bone. The sacrum is the third most common site of involvement. Clients present with localized pain in the lower back and sacrum that may radiate to one or both legs. Swelling may be noted in the involved area. When asked about the presence of other symptoms anywhere in the body, the client may report abdominal complaints and neurologic signs and symptoms (e.g., bowel and bladder or sexual dysfunction, numbness and weakness of the lower extremity).4,34,35

Colorectal or anorectal cancer as a cause of sacral pain is possible as the result of local invasion. Severe sacral pain in the presence of a previous history of uterine, abdominal, prostate, rectal, or anal cancer requires immediate medical referral.

Prostatic (males) or reproductive cancers in men and women can result in sacral pain. See further discussions on testicular cancer in Chapters 10 and 14, prostate cancer in Chapter 10, and gynecologic conditions in this chapter.

The Coccyx

The coccyx or tailbone is a small triangular bone that articulates with the bottom of the sacrum at the sacrococcygeal joint. Injury or trauma to this area can cause coccygeal pain called coccygodynia.

Coccygodynia

Most cases of coccygodynia or coccydynia (pain in the region of the coccyx) seen by the physical therapist occur as a result of trauma, such as a fall directly on the tailbone, or events associated with childbirth.

Symptoms include localized pain in the tailbone that is usually aggravated by direct pressure such as that caused by sitting, passing gas, or having a bowel movement. Moving from sitting to standing may also reproduce or aggravate painful symptoms.

In the case of persistent coccygodynia with a history of trauma, the therapist must keep in mind the possibility of rectal or bladder lesions (Box 15-3). When asked about the presence of other symptoms, clients with coccygodynia after a traumatic fall may also report bladder, bowel, or sexual symptoms. The therapist must ask whether bladder, bowel, or rectal symptoms were present before the fall. Because 50% of all clients with back or sacral pain from a malignancy have preceding trauma or injury, the apparent trauma (especially if the client reports associated symptoms that were present before the trauma) may be something more serious.

Box 15-3

Causes of Coccygeal Pain

• Diskogenic disease (herniation)

• Degenerative spondylolysis or spondylolisthesis

• Lumbar spinal stenosis

• Sacroiliac joint impairment

• Anal fissures

• Inflammatory cysts

• Prostatitis

• Thrombosed hemorrhoids

• Chordoma (neoplasm)

• Pilonidal cysts

• Trauma (fall, childbirth, anal intercourse)

• Nonunion fracture (sacrum, coccyx)

• Coccygeal disk injury (rare)

Data from Wood KB, Mehbod AA: Operative treatment for coccygodynia, J Spinal Disord Tech 17(6):511-515, 2004.

For possible clues to treating a client with coccygodynia, the therapist should review Box 15-3, keeping in mind the risk factors for each of these conditions. The therapist should also conduct a neurologic screening examination to identify any signs or symptoms of disk disease. Past history of any of the problems listed is a yellow (warning) flag. Blood in the toilet after a bowel movement may be a sign of anal fissures, hemorrhoids, or colorectal cancer and requires medical evaluation.

The Pelvis

Once again, the principles used in screening for systemic, medical, or viscerogenic causes of back, sacral, and SI pain also apply to pelvic pain. The history and associated signs and symptoms may vary somewhat according to the cause, but many of the causes are the same (e.g., cancer, GI, vascular, urogenital) (Table 15-2).

TABLE 15-2

Causes of Pelvic Pain

IUCD, Intrauterine contraceptive device; PID, pelvic inflammatory disease; IBD, inflammatory bowel disease, IBS, irritable bowel syndrome.

^*The combined medical and physical therapy differential diagnosis includes many origins of pathokinesiologic conditions, including joint laxity; subluxations or displacements; thoracolumbar hypermobility; bursitis; osteoarthritis; spondyloarthropathy; fracture; and postural, ligamentous, or osteoporosis/osteomalacia. (This list is not exhaustive.)

^†As with joint impairment, the differential diagnosis of muscle pathokinesiologic conditions can include many origins (e.g., trigger points, tendinous avulsion, strain/sprain/tear, weakness, loss of flexibility, pelvic floor overactivity [pain and spasm] or underactivity [laxity, weakness, and leaking], diastasis recti).

The most common primary causes of pelvic pain are musculoskeletal, neuromuscular, gynecologic, infectious, vascular, cancer, and GI (in descending order). For example, chronic pelvic pain is most commonly associated with endometriosis, adhesions, IBS, and interstitial cystitis. Infectious disease is the most common systemic cause of pelvic pain.36,37

The goal in screening is to identify individuals with infectious, vascular, or neoplastic causes of pelvic pain and refer those people appropriately while at the same time making sure that those individuals we treat have a problem within the scope of our practice. Therapists must keep in mind that pelvic pain and symptoms can be referred to the pelvis from the hip, sacrum, SI area, or lumbar spine. At the same time, pelvic diseases can refer pain or symptoms to the abdomen, low back, buttocks, groin, and thigh. This means that anytime a client presents with pain or impairment in any of these areas, pelvic disease must be considered as a possible cause. At the same time, keep in mind that pelvic floor muscle spasm can be associated with disorders such as IBS or adhesions secondary to interstitial cystitis; such problems can be aided by the therapist who is skilled in management of pelvic floor muscle impairments.

The anterior pelvic wall is part of the musculature of the abdominal cavity. The lateral walls are covered by the iliopsoas and obturator muscles, and inferiorly, the outlet is guarded by the levator ani and pubococcygeus (pelvic floor) muscles, with which the corresponding muscles of the opposite side form the pelvic diaphragm.

These two anatomic regions are separated only by walls of muscle. Because the pelvic cavity is in direct communication with the abdominal cavity (see Fig. 14-1), any organ disease or systemic condition of the pelvic or abdominal cavity can cause primary pelvic pain or referred musculoskeletal pain, as is described in this section.

The therapist should keep in mind that pelvic pain, pelvic girdle pain, and low back pain often occur together or alternately. Whenever discussing pelvic pain, the therapist should ask about the presence of unreported low back pain (including pelvic girdle pain). Pelvic girdle pain can occur separately or combined with low back pain and is defined as generally present between the posterior iliac crest (posterior superior iliac spine [PSIS]) and the gluteal fold in the vicinity of the SI joint.

Using the Screening Model to Evaluate the Pelvis

When our screening model is followed, the same steps are always taken. A personal or family history is obtained, and risk factor assessment is performed. Once the history has been established, the pelvic pain pattern is reviewed. The therapist looks for red flags that may suggest systemic, medical, or viscerogenic causes. Additional questions may be needed to complete the screening process. These questions are presented for all causes of pelvic pain at the end of this chapter.

History Associated With Pelvic Pain

With so many possible causes of pelvic pain, many different factors in the past medical history can raise a red flag. Pelvic pain is a very complex problem. Many medical texts are written about just this one anatomic area.

This text does not attempt to explain or discuss all the possible causes of pelvic floor or pelvic girdle pain. Rather, the intent is for the reader to learn how to screen for the possibility of systemic or viscerogenic sources of pelvic pain or symptoms. With a good understanding of what is important in the history and a list of possible follow-up questions, the therapist assesses each client, keeping in mind that medical referral may be needed.

Some of the more common red flag histories associated with pelvic pain are listed in Box 15-4. With the use of categories from the screening model, risk factors, clinical presentation, and associated signs and symptoms also are listed.

Box 15-4 Red Flags Associated with Pelvic Pain or Symptoms

History *

• History of reproductive, colon, or breast cancer

• History of dysmenorrhea, ovarian cysts, pelvic inflammatory disease, sexually transmitted disease

• Endometriosis

• Chronic bladder or urinary tract infections

• Chronic irritable bowel syndrome

• Previous history of pelvic/bladder surgeries, especially hysterectomy

• Recent abortion or miscarriage

• History of assault, incest, trauma

• History of prolonged labor; use of forceps or vacuum extraction during delivery

• History of multiple births

• Chronic yeast/vaginal infections

• History of varicose veins in the lower extremities (risk factor for pelvic congestion syndrome)

Risk Factors

• Recent intrauterine contraceptive device (rejection) or long-term use, especially without medical follow-up (scar tissue)

• Perimenopause, menopause (vaginitis, vaginal atrophy)

• Sexual activity without use of a condom (sexually transmitted diseases, pelvic inflammatory disease [PID])

• Multiple sexual partners (sexually transmitted diseases, PID)

• Pregnancy, childbirth, recent abortion, multiple abortions

Clinical Presentation

• Insidious onset; unknown cause

• Poorly localized, diffuse; client unable to point to one spot

• Aggravated by increased intraabdominal pressure (e.g., standing, walking, sexual intercourse, coughing, constipation, Valsalva’s maneuver)

• Pelvic pain is not affected by specific movements but gets worse toward the end of the day or after standing for a long time

• May be temporarily relieved by position change (e.g., getting off feet, resting or elevating the legs, putting the feet up)

• Pelvic pain is not reduced or eliminated by scar or soft tissue mobilization or by trigger point release of myofascial structures in the pelvic cavity

• Positive McBurney’s, Pinch an Inch, or iliopsoas/obturator sign (see Chapter 8)

• Presence of vulvar varicosities (seen most often in women with pelvic floor congestion syndrome and pregnancy)

Associated Signs and Symptoms

• Discharge from vagina or penis

• Urologic signs or symptoms

• Unreported abdominal pain

• Dyspareunia (painful or difficult intercourse)

• Constitutional symptoms

• Missed menses or unexplained/unexpected spotting (light staining of blood) (e.g., ectopic pregnancy) ask about shoulder pain

• Headache, fatigue, irritability

^*Many of the histories listed here are also risk factors for pelvic pain. Regarding pelvic girdle pain, according to the European Guidelines for the Diagnosis and Treatment of Pelvic Girdle Pain, red and yellow flags are the same for low back pain and pelvic girdle pain with the possible exception of age (pelvic girdle pain affects younger individuals less than 30 years old and is less likely to be caused by malignancy).³⁸

Most conditions that affect the pelvic structures are found in women, but men may also experience pelvic floor impairment and pain. Sexual assault, anal intercourse, prostate or colon cancer, and sexually transmitted disease (STD) are the most common causes for men. Prostate problems such as benign prostatic hyperplasia (BPH) or prostatitis can cause lower abdominal, back, thigh, or pelvic pain. These conditions are discussed in Chapter 10.

Clinical Presentation

In the screening process, clinical presentation and especially pain patterns are very important. Mechanisms of viscerogenic pain (i.e., how these patterns develop) are discussed in Chapter 3.

Pelvic pain may be visceral pain, caused by stimulation of autonomic nerves (T11 to S3); somatic pain, caused by stimulation of sensory nerve endings in the pudendal nerves (S2, S3); or peritoneal pain, caused by pressure from inflammation, infection, or obstruction of the lining of the pelvic cavity.

Peritoneal pain may be caused by disruption of the autonomic nerve supply of the visceral pelvic peritoneum, which covers the upper third of the bladder, the body of the uterus, and the upper-third of the rectum and the rectosigmoid junction. It is not sensitive to touch but responds with pain on traction, distention, spasm, or ischemia of the viscus.

Peritoneal pain may also occur in relation to the parietal pelvic peritoneum, which covers the upper half of the lateral wall of the pelvis and the upper two thirds of the sacral hollow—all supplied by somatic nerves. These somatic nerves also supply corresponding segmental areas of skin and muscles of the trunk and the anterior abdominal wall. Painful stimulation of the parietal pelvic peritoneum may cause referred segmental pain and spasm of the iliopsoas muscle and muscles of the anterior abdominal wall.

Knowing the characteristics of pain patterns typical of each system is essential. When the client describes these patterns, it is possible for the therapist to recognize them for what they are and to see how the clinical presentation differs from neuromuscular or musculoskeletal impairment and dysfunction.

Pelvic disease may cause primary pelvic pain and may also refer pain to the low back, thigh, groin, and rectum. Usually, pelvic disease appears as acute illness with sudden onset of severe pain accompanied by nausea and vomiting, fever, and abdominal pain. Mild-to-moderate back or pelvic pain that gets worse as the day progresses may be associated with gynecologic disorders. The therapist is more likely to see the atypical presentation of systemically related central lumbar and sacral pain, which is easily mistaken for mechanical pain.

Associated Signs and Symptoms

While collecting pertinent personal and family history, conducting a risk factor assessment, and evaluating the client’s pain pattern, the therapist listens and looks for any yellow or red flags. From there, the therapist formulates any additional questions that may be appropriate on the basis of data collected so far. Before leaving the screening task, the therapist asks a few final questions. The first is about the presence of any associated signs and symptoms.

For example, perhaps the client has pelvic pain and unreported shoulder pain. She may not think her previously unreported shoulder pain has any connection with the current pelvic pain, or she may not see that the presence of a vaginal discharge is linked in any way to her low back and pelvic pain. Discharge from the vagina or penis (yellow or green, with or without an odor) in the presence of low back, pelvic, or sacral pain may be a red flag.

To bring this information out and make any of these connections, the therapist must ask about the presence of any associated signs and symptoms. Ask the client the following:

Follow-Up Questions

• Do you have any symptoms anywhere else in your body? Tell me even if you don’t think they are related to your pelvic pain.

If the client says “No,” then ask about the presence of urologic symptoms and constitutional symptoms, and look for a connection between the menstrual cycle and symptoms. If it appears that there may be a gynecologic basis for the client’s symptoms, the therapist may want to ask some additional questions about missed menses, shoulder pain, and spotting or bleeding.

The therapist should assess for the presence of dysmenorrhea, defined as painful cramping during menstruation. Dysmenorrhea may be primary (of unknown cause) or secondary as a result of a pelvic pathologic condition related to endometriosis, intrauterine tumors or polyps (myomas), uterine prolapse, pelvic inflammatory disease (PID), cervical stenosis, and adenomyosis (benign invasive growths of the endometrium into the muscular layers of the uterus).

Dysmenorrhea is characterized by spasmodic, cramp-like pain that comes and goes in waves and radiates over the lower abdomen and pelvis, thighs, and low back, sometimes accompanied by headache, irritability, mental depression, fatigue, and GI symptoms.

Screening for Neuromuscular and Musculoskeletal Causes of Pelvic and Pelvic Floor and Pelvic Girdle Pain

The therapist is most likely to see pelvic floor pain and/or pelvic girdle pain that are caused by neuromuscular or musculoskeletal problems. Pelvic pain or symptoms may be referred from systemic or neuromusculoskeletal origins from the hip, SI joint, sacrum, or low back.

Pelvic floor pain can present suprapubically, perineally, and/or in the low buttock/anal areas. Pelvic girdle pain can occur separately or combined with low back pain and is defined as generally present between the posterior iliac crest (PSIS) and the gluteal fold in the vicinity of the SI joint. Pain may radiate to the posterior thigh; endurance for standing, walking, and sitting is decreased.³⁸ Pelvic girdle pain occurs most often during pregnancy or continues many years postpartum. Many women have both pelvic floor and pelvic girdle pain, requiring each to be addressed externally and internally.

Likewise, pelvic diseases can refer pain and symptoms to the low back, groin, and thigh. When evaluating low back or pelvic pain, the therapist must assess for pelvic floor laxity or tension, psoas abscess, trigger points, history of birth or sexual trauma, and the presence of any associated signs and symptoms.

Neurologic disorders (e.g., nerve entrapment, incomplete spinal cord lesion, multiple sclerosis, Parkinson’s, stroke, pudendal neuralgia) can cause pelvic pain and dysfunction. Pudendal nerve entrapment is characterized by pain relief when one is sitting on a toilet seat or standing; elimination of symptoms after a pudendal nerve block is diagnostic.

Musculoskeletal impairment of the pelvic floor and low back may manifest as dyspareunia (pain before, during, or after intercourse). Overactivity (pain and spasm; muscles contract when they should relax or do not relax completely)⁴¹ of the pelvic floor and pelvic floor trigger points can contribute to entrance (superficial or deep) dyspareunia. Deep thrust dyspareunia may also be related to SI or low back impairment. Dyspareunia symptoms that are reduced in alternate positions may indicate a musculoskeletal component, especially when other signs and symptoms characteristic of musculoskeletal impairment are also present.^42,43

One of the most common musculoskeletal sources of pelvic floor pain in men and women is the trigger point. Muscles most likely to cause or refer pain to the pelvic area include the levator ani, abdominals, quadratus lumborum, and iliopsoas.44–46

Typical aggravating and relieving factors for pain from a neuromuscular or musculoskeletal source include the following:

• Aggravated by exercise, weight bearing

• Aggravated by trunk/lumbar rotation

• Relieved by rest or stretching

• Pain or altered movement pattern produced by trunk and lumbar rotation

• Eliminated by trigger point therapy

The therapist looks for a contributing history such as a fall on the buttocks, pregnancy, or trauma. Avulsion of hamstrings from a sports injury may be reported. Trauma from physical or sexual assault may remain unreported. Screening for assault is an important part of many evaluations (see Chapter 2).

The therapist also looks for muscle impairment. For therapists trained in pelvic floor muscle examination, external and internal palpation of the pelvic floor musculature is helpful.47,48 Examination also includes observation for varicosities and assessment of muscle tone (muscle overactivity [pain and spasm] or underactivity [laxity with weakness and leaking] and the presence of trigger points.^44,49,50 Transabdominal ultrasound and vaginal dynamometer are two tools used by some physical therapists to assess pelvic floor muscle contraction. Many clients who experience low back, pelvic, SI, sacral, or groin pain have unrecognized pelvic floor impairment.⁵¹

Pain provocation tests for the symphysis pubis and SI joint (e.g., Patrick’s/Faber’s, modified Trendelenburg, Gaenslen’s, shear, P4, gapping, and compression tests), palpation, and mobility testing help point to pelvic girdle impairment, but this could be associated with primary pelvic floor impairment so that both problems coexist.⁵²

The treatment strategy may be to address the pelvic girdle pain first; if it does not resolve, then a pelvic floor muscle examination may be needed to confirm pelvic floor impairment. P4 is a pelvic floor muscle examination that refers to the “provocation of posterior pelvic pain” screening test for pregnancy-related pelvic girdle pain.⁵² Reliability and validity of the provocation tests mentioned here have been evaluated and reported; for details see Vleeming³⁸ and Olsen.⁵² Imaging tests, such as x-rays, computed tomography (CT), and magnetic resonance imaging (MRI), help rule out problems such as fractures, ankylosing spondylitis, and reactive arthritis.³⁸

Fig. 15-2 gives a simple representation of how the puborectalis muscle acts as a sling around various structures of the pelvis. The condition and position of the pelvic sling are very important in the maintenance of normal pelvic floor health.

Fig. 15-2 Pelvic sling. Puborectalis muscle forms a U-shaped sling encircling the posterior aspect of the rectum and returns along the opposite side of the levator hiatus to the posterior surface of the pubis. This shows how the condition and position of the pelvic sling contribute to the function of the pelvic floor and the encircled viscera. Obesity, multiparity, and prolonged pushing during labor and delivery are just a few of life’s events that can disrupt the integrity of the pelvic sling and the pelvic floor. (From Myers RS: Saunders manual of physical therapy practice, Philadelphia, 1995, WB Saunders.)

Fig. 14-1 provides a visual reminder that the muscles of the pelvic floor support the reproductive organs and the viscera in the peritoneum. Any impairment of these organs may cause impairment of the pelvic floor and vice versa. Any weakness or impairment of the pelvic floor can lead to problems with the viscera located in the abdominal or pelvic cavities.