3.1 Initial Observation

The evaluation is to begin in the waiting room, as the patient is completing her intake paperwork. Observing the patient while she is acting independent of an actual “evaluation” will shed light on her sincerity and level of dysfunction. Caution is necessary when the observed behaviors in the waiting room vary drastically from those in the formal evaluating room. Movement patterns, postural proclivities, and gait anomalies are also to be documented while the patient is involved in activities that are not directly “evaluation” related: movement from car to office, filling out paperwork, and interacting with others while waiting for the evaluation to begin. Disparities give the clinician room for consideration when determining whether an internal evaluation is appropriate. Essentially, begin to deduce what is the general appearance and presentation of the patient, and whether behavior is consistent.

Summary of observations to make:

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  Is she holding herself in a protected fashion?

  
  
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  Is she interactive or withdrawn?

  
  
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  Is she demonstrating distressed behaviors?

  
  
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  Is she standing quietly or pacing the room?

  
  
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  How does she move from the waiting room to the evaluation room?

3.2 History

Once the patient is in the evaluation room, a thorough history is to be taken. While conducting the verbal history, the clinician needs to listen for specific cues that will assist in ascertaining the patient’s symptoms. The location and quality of symptoms should be elicited from the patient, who should be encouraged to be specific and concise. The purpose of subjective examination is to determine what the patient is experiencing, and how she relates to this experience. Using open-ended questions allows the patient to freely express herself, often offering information that is apropos to forming an accurate diagnosis. These questions allow the clinician the opportunity to evaluate the patient’s perceived level of disability, her coping strategies, her support system, her emotional integrity, and to what degree her activities have been limited. The report of cramping pain is suggestive of visceral involvement, especially when it correlates with visceral dysfunction. ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ Visceral pain has been described as being a dull, poorly circumscribed ache that is experienced at various areas of the pelvis, whereas burning pain suggests neuropathic pain. ¹⁴

Questions to be covered during the evaluation:

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  Has she given birth?

  
  
  
  
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    Vaginally or cesarean section?

  
  
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  Is she working?

  
  
  
  
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    What is required of her during vocational duties?

  
  
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  Familial history of:

  
  
  
  
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    Endometriosis

    
    
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    Vulvar skin disease

  
  
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  Does she have a sexually transmitted disease?

  
  
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  When does she feel her pain?

  
  
  
  
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    What aggravates her pain?

    
    
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    What minimizes her pain?

  
  
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  How does she cope with her pain?

Questions regarding child bearing, surgical history, and/or the presence of endometriosis are appropriate and necessary. Five to 20% of postpartum women experience pelvic girdle pain without a statistically significant difference between muscle thickness of the deep abdominal muscles and strength of their PFM. ¹⁵ , ¹⁶ , ¹⁷ It has been reported that second-stage labor places a 34.5% and 32.9% strain on the inferior and perineal nerve, respectively. ⁶ , ⁷ This is well beyond the 15 to 20% percent strain of a nerve that is known to cause nerve injury. ¹⁸ , ¹⁹ , ²⁰

It has been reported that 80% of the pelvic pain population ⁶ , ⁷ has endometriosis; this population is capable of localizing their pain to the site of the endometriosis lesion. ²¹

Does the patient have a surgical history along the abdomen and/or saddle region that warrants further evaluation? Local scarring may impede mobility, strength of the underlying musculature, or be a source of low-level persistent pain.

The clinician’s questions from this domain should include:

Do the symptoms indicate neurological entrapment?

Are the patient’s symptoms referred? If so, what neurological structures can refer to the region outlined by the patient? Is there a specific dermatome outlined, or does the patient’s pain indicate a cutaneous nerve entrapment? What joints, organs, and myofascial restrictions can refer to the region outlined by the patient? All must be considered while performing the evaluation.

What influences the symptoms?

How have the symptoms progressed or changed over time?

After compiling this information, the clinician will begin to have an understanding as to why the patient has her symptoms, inclusive of an understanding of the various structures that may demonstrate these symptoms, and in this location. This suggests that every pain has a source, and it is the clinician’s responsibility to determine the exact source to determine the appropriate treatment regimen. ³ , ²²

The last domain that the clinician will focus on is the extent to which the symptoms affect the patient’s quality of life and how encompassing this problem is for this patient. How is this patient coping, and does she have the fortitude for an internal evaluation? During the course of the history taking, the clinician will be attempting to determine the patient’s relative state of anxiety associated with her pelvic pain condition, in addition to her general state of anxiety. There is a strong, positive correlation between anxiety, depression, and sexual dysfunction in women with chronic pelvic pain and the clinician must be cognizant of the patient’s emotional maturity and disposition to minimize her risk to litigation and to ensure her comfort. ²³ , ²⁴

During the medical history, the astute clinician will inquire about skin diseases elsewhere on the body, and also gather a family history of skin diseases as this patient may be more predisposed to developing vulvar skin diseases. The history should be inclusive of illnesses including diabetes mellitus, malignancy, and so forth.

3.3 Postural Observation and Inspection

The angle of declination is a measurement that is to be taken during the course of the evaluation, and it is defined as an imaginary line between the posterior superior iliac spine (PSIS) and the anterior superior iliac spine (ASIS), and is compared with the horizontal (Fig. 3.2) . A normative value for women is 10 to 20 degrees. An angle more than 20 degrees strongly indicates a weakness or inability to functionally utilize the abdominal and pelvic musculature. A lessening of the angle often leads to a flattening of the lumbar lordosis.

“Asymmetry is the norm,” but it is also a component of soft-tissue changes of the paraspinal musculature, compensatory postures, and altered mechanics of the spine. ²⁵ Al-Eisa et al found that those with either a lateral pelvic tilt (LPT), where the ASIS and PSIS was higher on one side, or an iliac rotation asymmetry (IRA),where the ASIS was higher and PSIS was lower, demonstrated significant differences in coupled lumbar rotation during lateral flexion than those with normal symmetry. ²⁶ , ²⁷ They concluded that subtle anatomic abnormalities of the pelvic bone alignment were associated with altered mechanics of the lumbar spine and that it may be a better indicator of functional deficit than absolute range of motion in individuals with lower back pain. ²⁶ , ²⁷ Therefore, when evaluating patients, noting positional asymmetries is appropriate to have a means of future comparison and also to assist in the formation of a functional diagnosis that is unique to each patient.

Asymmetrical proclivities and postural habits can facilitate a series of muscle imbalances that will promote the shortening and tightening of muscle groups with antagonists elongating, demonstrating weaknesses and relative hypertrophy; atrophy of antagonistic musculature, along with a loss of fine motor control reflect a degradation of integrated muscle function. ²⁵ Clinically, this is seen as the patient’s way in which they hold themselves; in standing and in sitting. Muscles continually adapt to the body’s orientation and postures as related to gravity; and faulty postures will result in an alteration of the center of gravity that will have consequences within the joints and muscular systems. Persistent aberrant afferent mechanoreceptor facilitation due to faulty postures and positions will cause a change in spinal cord stimulation leading to muscle imbalances. Muscle balance will be altered in response to noxious stimuli and central mediation through the lateral reticular system, altering the activity of the gamma motor neurons, resulting in hyperreflexia and altered activation sequencing of muscle action; constant abhorrent neurological stimulation will increase the patient’s experience of pain. This enhanced nociception will further facilitate alpha motor neurons segmentally, possibly leading to a progression of pain to a somatic structure that shares a common embryogenesis. Psychological predispositions can further influence muscle balance and resting tone. ²⁵

Often it is the case that the patient, in an attempt to stabilize the lumbosacral spine, is compliant with performing an abdominal strengthening regimen. If the pelvic floor musculature is compromised in any fashion, it is possible that a disassociation will occur between the innominate and the sacrum itself. In such a scenario the angle of declination may be appropriate while the sacrum is found to be hyper-nutated. The result is often palpable as globular nodules along the SIJ posteriorly. This is demonstrated in Fig. 3.3 . The clinician should consider what has occurred to the anterior SIJ ligament in this scenario.

3.4 Evaluation General Concepts

The clinician should incorporate a progressive schema when examining a patient with pelvic pain. This approach takes into consideration that the practitioner is accomplished at performing an evaluation and interpretation of the thoracic, lumbar, and sacral spines, as well as the hips and pelvic ring complexes. The proceeding framework is progressive in nature and allows the slow integration of the patient into the differential diagnostic model. This premise also helps the clinician decide whether or not it is appropriate to expose the saddle region and perform an internal examination. Evaluations must include a thorough medical history, a complete inspection, and a carefully conducted functional examination with any appropriate accessory tests. Upon completion of the evaluation, the clinician needs to interpret the resultant positive and negative findings that will offer insight into the origin of the pain and provide the basis of the clinical diagnosis. ³ , ²²

Despite the fact that the following framework is a symptom reproduction model, during the course of evaluating and treating a patient with pelvic pain the clinician will best serve the patient by having her avoid those activities and treatments that induce excessive pain or discomfort. The extent of a patient’s experienced pain has a direct relationship between the number of painful experiences and the extent of hyperalgesia that patient experiences. The clinician, therefore, is to minimize painful experiences during the evaluation and subsequent treatment sessions. ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³²

The clinician is to take into consideration that a woman’s pain threshold fluctuates throughout her menstrual cycle. The tolerance to pain is less during the premenstrual phase and greatest during the luteal phase. Those suffering from dysmenorrhea will experience a greater reduction in their tolerance to pain after the cessation of their menses, especially along the abdomen. ³⁰

Finally, the clinician must be aware of the signs and symptoms of vulvar skin disease (Fig. 3.4) . Such signs and symptoms include: pruritus, burning, pain, soreness, changes in appearance of the vulva, or abnormal discharge. These patients will often complain about symptom exacerbation with micturition, intercourse, and the menstrual cycle. Examination of the vulvar region and perianal region will further assist in determining the possibility of a vulvar skin disease. Splits and fissures should be noted and questioned as to their duration. There are four types of skin conditions about which the clinician should be aware: (1) inflammatory disorders, (2) infections, (3) tumors, and (4) blistering disorders. Inflammatory disorders include dermatitis (eczema), contact dermatitis, psoriasis, lichen planus, and lichen sclerosus. Infections include fungal, bacterial, viral, and infestations: candida, trichomonas vaginalis, and herpes. Tumors can be either benign or malignant, including malignant melanoma and squamous cell carcinoma. Blistering disorders include pemphigus and pemphigoid. ²¹ , ³³ , ³⁴ , ³⁵ , ³⁶

During the course of the evaluation, the clinician will take note of specific movements and special tests (which will be discussed later in the text), to note how the patient responds. Do the actions and tests either produce or decrease the patient’s symptom(s)? The clinician is to maintain a sound understanding of the various pain referral pattern of the involved anatomy and is to methodically rule each structure in or out as to whether or not it is causative in each patient’s pain or dysfunction. Knowledge of common embryological origin of the visceral structures and their ability to refer intrasegmentally, within that segment to those somatic structures that share the same segment, is useful in making a diagnosis. Considering the multisegmental innervations of the viscera and PFM, the musculoskeletal screening portion of the examination includes the thoracic, lumbar, sacral spines, and the hip joints, noting subtle patterns to deduce a common segmental level of involvement or implication of a mechanical lesion of the spine or hip. ³ , ²¹ , ²² , ³⁷ In summary, the clinician is to evaluate how the entire system is functioning as a whole. The following hierarchy is utilized in determining the likely pain-perpetuating source:

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  Biopsychosocial factors

  
  
  
  
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    Somatization

    
    
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    Perseveration

    
    
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    Anxiety

  
  
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  Neurological

  
  
  
  
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    Referred pain

    
    
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    Centralization, convergence, and sensitization

  
  
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  Joint Restrictions

  
  
  
  
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    Facet inflammation/referred pain

    
    
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    Internal derangement of hip

    
    
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    Arthropathy

  
  
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  Scar presence and restrictions

  
  
  
  
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    Abdominal

    
    
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    Perineal

    
    
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    Hip

  
  
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  Muscle imbalance and generalized weakness

  
  
  
  
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    Postural faults

    
    
    
    
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      Sitting

      
      
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      Standing

Despite the contradictions in SIJ literature as related to the general orthopedic population, those patients with pelvic pain and a history of pregnancy tend to exhibit asymmetrical SIJ laxity. It has been found that subjects with moderate to severe pregnancy-related pain and asymmetrical laxity of the SIJ (as confirmed via DUS) have a threefold higher risk of moderate to severe postpartum pelvic pain. ³⁸ One-hundred percent of the 16 subjects in the Lukban et al study tested positive for SIJ dysfunction with a 94% improvement of dyspareunia, painful sexual intercourse, after undergoing treatment directed at the SIJ. ⁵ , ³⁹

3.5 Spinal Examination

The evaluation of the patient suffering from pelvic pain and dysfunction is to be inclusive of the thoracic, lumbar, and sacral spines, in addition to the SIJs and the coxofemoral joints. Each of the aforementioned structures can refer pain to the pelvis, and must be ruled out prior to considering performing an internal evaluation. The examination process presented here follows the guidelines of Dr. James Cyriax. Unlike many orthopedic conditions where there are often many clinically definitive findings that implicate a particular structure as the source of the patient’s pain, findings in the patient suffering with pelvic pain may not be as clear-cut. The clinician must take into consideration the aforementioned structures, their referral patterns, and the multitude of structures outlined previously when evaluating this patient population. The patient suffering from any chronic malady, let alone pelvic pain, will often have a plethora of ailments that lie over one another. This can be quite confounding to the novice and experienced clinician alike. During the course of the evaluation, the clinician is to note whether or not the findings of the evaluation are concurrent, causational, or correlational. ³ , ²² , ³⁷

Concurrent findings are those that parallel the patient’s primary complaint. They may directly or indirectly perpetuate the patient’s pain cycle. The most common example would be the attaining and maintaining of a forward flexed posture, a slouched position. In such a position, the dural tube is placed under considerable strain, and as was stated in the neurological discussion in Chapter 2, the dura mater is highly sensitive to stretch. This hyperkyphotic alignment of the spine also enhances the posterior migration of the intervertebral disks, further compromising dural mobility and increasing the likelihood of a disk lesion. Causational findings are those that test positive during the evaluation, where the symptoms are reproduced, and give a clear-cut diagnosis in this patient population. A common example would be the patient with an acute primary posterolateral disk lesion where a specific event initiated the patient’s symptoms, and a specific movement reproduces these symptoms. Correlational findings will be the most nuanced and difficult to ascertain. The clinician will often have subtle hints as to the locality of pain origination and propagation. This is most commonly noted in the presence of a centrally sensitized segment of the spinal column. Often difficult to specifically test with one maneuver, the clinician is forced to make determinations based upon the composite of subtle indications and knowledge of the embryological derivation of the pelvic structures. Table 3.1 is a summary of the visceral structures and their embryological somites.

After having observed the patient’s resting sitting and standing proclivities, and having noted the relative angle of declination, symmetry of stance, and ease to which they hold themselves (are they fidgeting?), the clinician can initiate the spinal screening. This begins with the patient standing with their back to the clinician. The clinician runs a hand down the length of the spine to note the presence of a step deformity, indicating the possible presence of a spondylolisthesis. After which time, the clinician rests his or her hands upon the iliac crest in full pronation with a firm, yet gentle pressure. This allows for the opportunity to notice the patient’s tolerance to touch in addition to providing the clinician the means to determine whether or not there is symmetrical tone of the local musculature and relative iliac crest heights. While maintaining the pronated position of the forearm, the clinician is to sweep his or her thumbs along the posterior iliac crest in such a fashion that the subtle rise and fall can be appreciated. The sweeping thumb will rise, and then fall over the posterior aspect of the iliac crest posteriorly. Once the thumb has “fallen,” the clinician is to turn the thumbs cranially, and then press up. There should be a feeling of a firm end. This is the PSIS; S2 can be found as a midpoint between the two PSISs. Next, the patient is asked to side bend to the left, and then right, and then to extend backward toward the clinician. Once those motions are completed, and with the clinician’s palpating digits upon the PSIS, the patient is asked to forward flex. This is the standing flexion test of the SIJ. A greater migration of one of the PSIS points as compared with the opposite indicates that a hypomobility may exist on the side that moved the greatest. The following test, known as the Gillet test (or march test, or stork test) is then readily performed as the clinician’s hands are prepositioned. With one palpating digit maintained at the PSIS, the opposite thumb is moved to the sacral body. The clinician then asks the patient to flex the hip that corresponds to the thumb that is maintained at the PSIS. During the movement of the hip, the clinician notes the relative movement of the PSIS thumb to that of the sacral thumb. Normal movement is considered when the PSIS thumb moves first and the sacral thumb moves second. Hypomobility of the ipsilateral SIJ is suspected when the two, PSIS and sacrum, move as a unit. These two findings together allow the clinician the opportunity to appreciate the local mobility of the SIJ, and its potential as a pain generator can be appreciated.

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