The Pelvic Girdle Musculoskeletal Method - Introduction

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Introduction

Overview of PGM Method

The Pelvic Girdle Musculoskeletal Method has been developed by Deborah Riczo, a physiotherapist and leading expert in the field of pelvic girdle pain. She has been teaching this method since 2011.

Components of PGM Method

The PGM method is a holistic approach to pelvic girdle pain and includes the following components

Clinical history/pain location – see Recognising Pelvic Girdle Pain page

Special tests – tools to use to identify pelvic girdle pain

Pelvic sacral balancing exercises – interventions to use to correct issues of innominate and sacral positional strain

Targeted strengthening exercises

Targeted stretching exercises

Core strengthening

Patient education

Consideration of sacroiliac belt

PGM Method Special Tests

This method includes two sets of special tests to assess dysfunction. For the purpose of this course dysfunction refers to tendencies for certain positional strain caused by muscles that are being overstrained versus a positional change.

Innominate dysfunction cluster of special tests

Sacral dysfunction special tests

It is important to screen the innominate first.

Innominate Imbalance Special Tests

These are a cluster of 4 special tests and 3 out of 4 of these tests must be positive

Asymmetrical hip rotation range of motion (ROM)

Comparison of hip internal and external range of motion between sides.

Use an inclinometer or smartphone application to measure the range of motion

A difference of more than 10 degrees between left and right internal hip rotation is deemed as a positive test result

Look out for:

Perceived tightness unilaterally

Reproduction of symptoms unilaterally

Evidence for relationship of hip range of motion and low back pain and pelvic girdle dysfunction

Ellison et al, 1990 reported differences in hip rotation in patients with low back pain compared to patients without low back pain (controls). The researchers reported that the total hip external rotation was greater than the total hip internal rotation in patients with low back pain. A significant result was a difference of more than 10 degrees.

Cibulka et al, 2002 indicated that the presence of asymmetrical hip rotation range of motion may be an indication of sacroiliac region pain

Prather et al, 2017 indicated an association between reduced hip internal rotation and low back pain

Hartigan et al 2020 investigated hip angles, joint moments and muscle activity during gait in women with self-reported stress urinary incontinence and found the following in this population:

Weakness, poor endurance and timing of the pelvic floor muscles

Decreased ability of hip position control in the non-dominant leg

Decreased strength of the hip abductors and hip external rotators

Increased gluteus maximus activity of the non-dominant leg

Women with stress urinary incontinence present with altered hip biomechanics during the stance phase of gait. Although women with sui seem to be using greater hip abduction and external rotation forces, motor control strategies seem to be lacking and unable to avoid greater hip adduction and internal rotation positions. Hartinger 2020

Reliability of test – Inter- and Intra-rater reliability established for measurement of hip internal and external rotation in prone (Ellison 1990)

Measurement of hip internal and external rotation in prone

Hip internal rotation (IR) and external rotation (ER) is measured with the subject in prone, with hip n neutral position and knees flexed to 90 degrees. The goniometer is centred at the joint line, with the movement arm of the goniometer aligned along the midline of the tibia and the stationary arm aligned perpendicular to the floor (ref 39) Subject is asked to move hip into internal rotation while keeping the hips stationary on the table. Subject is then asked to move hip into external rotation while keeping the hips stationary on the table. Measures are assessed on the contralateral hip as well.

Smartphone application

Clinometer app

The top of the smartphone is placed 3cm below the tibial tuberosity and the base of the smartphone is positioned towards the midline of the medial and lateral malleoli Charlton 2015 Subject is asked to move hip into internal rotation (IR) and then into external rotation (ER). The clinician provides verbal cues to ensure that no compensatory movements occurs during the motion Cheatham 2017 Measures are also assessed on the contralateral limb. Recent research demonstrated moderate to excellent intrarater reliability for the measurement of active hip IR and ER when using the goniometer and a smartphone application (Clinometer). Good to excellent interrater reliability was also reported with the measurement of active hip IR and ER with both goniometer and smartphone application. Additionally, it is suggested that the smartphone application may be a valid alternative to hand-held goniometry when measuring active hip IR and ER in clinical practice. (Miley et al 2019)

Measurement of hip rotation in sitting

See this PP page

Hip rotation can also be measured in supine

Asymmetry/ tenderness of the symphysis pubis

Palpation of the symphysis pubis

If unilateral tenderness is present upon palpation of the symphysis pubis, this is considered as positive in the PGM method

Palpation of the anterior surface of the symphysis pubis with the person in supine have been shown to be 60% sensitive and 99 % for specificity when trying to elicit pain that persists for more than 5 seconds after removal of the examiner’s hand. Albert 2000

On palpation, anteroposterior or superoinferior displacement of the upper border of the pubic symphysis or pubic tubercle can also be felt Jain et al 2006 This may sometimes be more difficult for example in the third trimester of pregnancy.

A painful unilateral response on the side that the patient is complaining of the pain is a positive result in the PGM method

Range of motion at symphysis pubis

Garras et al (2008) investigated the range of movement at the symphysis pubis by using single leg stance radiographs. Multiparous women had a significantly increased physiologic range of pubic translation compared to men and nulliparous women. Up to 5 mm of physiologic motion can occur at the pubic symphysis in asymptomatic individuals.

Unilateral tenderness of ASIS and/or iliac crest

Only investigating tenderness of the iliac crest and/or the anterior superior iliac spine as part of the PGM method.

Research has shown a good discriminative ability and inter-rater reliability when two criteria (localised tenderness and pain recognition) were combined (Njoo and van der Does)

Good interobserver agreement was reported for “localised tenderness” and “typical pain” criteria on iliac crest pain syndrome in patients with non-specific low back pain (Njoo, 1995)

McCombe et al 1989 reported that palpation tests for bony tenderness was more reliable than palpation tests for soft tissue tenderness

Unilateral tenderness of PSIS and/or long dorsal sacroiliac ligament

The long dorsal sacroiliac ligament is known as a major pain generator for pelvic pain (Vleeming 1996, 2002)

Tenderness on palpation of this ligament does seem to indicate sacroiliac joint pain versus a low back problem

The sensitivity of this palpation test increases when it is combined with the active straight leg raise test and the thrust test. Vleeming 2008

Sacral Imbalance Tests

Two reasons for performing the sacral tests in the PGM method:

1. Negative cluster of PGM signs for the innominate (less than 3 out of 4 positive tests), but the patient has clinical history and symptoms consistent with sacroiliac pelvic girdle pain

2. After having done the interventions for the innominate dysfunction to address the positional strain, the patient’s symptoms clears up and innominate tests are no longer positive, but the patient are still displaying some clinical signs and complaints of sacroiliac pain or pelvic girdle dysfunction.

Pain upon sacral springing

Sacral gross springing – similar to the sacral thrust test

Patient in prone, therapist using pisiform of hand and applying gentle springing of the sacrum

If this relieves symptoms of patient, this can be used as a treatment technique

If  not painful with this test, but pelvic girdle dysfunction is still suspected, move on to assessing each individual pole of the sacrum

Individual springing of 4 poles of sacrum

Right and left base of sacrum

Right and left inferior lower angle of sacrum (ILA)

If symptoms are relieved with the individual springing this can be used as treatment

Take note of the pain provocation pattern when performing the individual springing of the 4 poles of the sacrum

Pain Provocation Patterns

Diagonal

For example, painful with springing of R superior pole and L inferior lateral angle (ILA) of sacrum, this may a torsion dysfunction

Vertical

For example, pain provocation with springing of R superior pole and R inferior lateral angle of sacrum, this may indicate the presence of an up slip or down slip. This is often best treated with postural type education and manual myofascial releases (Course)

Horizontal

Pain provocation painful on both superior poles or inferior lateral angles of sacrum (ILA)

This is not a torsion or up slip/down slip dysfunction and would more likely indicate a positional postural type dysfunction (course)

Virtual assessment of patient with pelvic girdle dysfunction

The COVID-19 pandemic has brought telehealth and virtual patient assessments to the forefront in physiotherapy. For more info on Telehealth and rehabilitation have a look at these pages.

When virtually assessing a patient with pelvic girdle dysfunction here are some recommendations on what to assess and how to do this (course)

Patient in standing

Assess tenderness or pain with palpation of ASIS

Assess tenderness or pain with palpation of symphysis pubis – look for tenderness on one side (the side where they are experiencing symptoms)

Assess tenderness of PSIS and iliac crest

Assess tenderness of long dorsal sacroiliac ligament (ask patient to drop thumb down and medial from PSIS and feel for tenderness)

Patient in sitting

Hip range of motion

Patient can place one foot on contralateral knee (figure of 4)

From this position, patient can bring leg across the body and assess pain with this movement

Knee to chest

Also assess transitional movements when patient moves from sitting to supine

Patient in supine

Knee to chest

Figure of 4 (placing foot on contralateral knee)

Hamstring length

Patient can also palpate bony landmarks in supine

It is also recommended to rule out centralisation with the McKenzie approach (repeated back extensions or prone press-ups) If symptoms centralise, then the PGM method is not the way to go.

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