The pelvis provides a bony link between the flexible spine and the lower limbs and provides a stable hub or platform for the transmission of forces across the pelvis as well as providing attachment sites for some 35 muscles. When considering the role of the pelvis in relation to other musculoskeletal disorders and sporting injuries it is important to consider the complex interaction of the various joints, ligaments, muscles and nerves of lumbo-pelvic-hip region.
Stabilisation of the lumbo-pelvic-hip region is required during all motion. The joints of the pelvis which are the pubic symphysis and sacro-iliac joints (SIJ) must be able to absorb and transmit these forces efficiently for optimal function of the spine and lower limbs. Lumbo-pelvic dysfunction occurs as a result of altered joint biomechanics at either the pubic symphysis or sacro-iliac joint (SIJ), imbalances of the lumbo-pelvic-hip muscles or altered recruitment of lumbo-pelvic core stability muscles.
Altered joint mechanics leads to abnormal muscle activation with poor timing and inappropriate patterns of muscle activation. This in turn may lead to altered translational joint forces at the SIJ and pubic symphysis and may lead directly to injury of these joints but often results in a subsequent cascade of events with injuries to the hip, groin, knee and foot.
The iliotibial band commonly referred to as the ITB is a tight fibrous band of connective tissue extending along the lateral aspect of the thigh. It attaches from the iliac bone of the pelvis above and extends down the side of the thigh and then it crosses over the lateral aspect of the knee joint. The ITB also has some fibres attaching into the patella) but finally the ITB inserts below the knee at the upper ends of the tibia and fibula (the lower leg bones).
This important structure to which other muscle such as the gluteals, quadriceps and hamstrings have attachments helps to stabilise the hip and lower limbs and has an important role in controlling knee function. Weaknesses in part of the gluteal muscle in addition to pelvic/SIJ dysfunction can result in symptoms with patients presenting with what has been incorrectly diagnosed as “ITB syndrome” or “patellofemoral dysfunction”. Instead, a patient may indeed have a problem arising from the lumbo-pelvic region with a SIJ dysfunction.
In addition to assessing the local problem areas, treatment should be directed to assessing pelvic joint motion, core stability, and muscle imbalances of the lumbo-pelvic-hip region in order to provide a more complete understanding of what contributed to this injury and why isolated treatment has not provided for a more complete recovery and return to sporting activities.
Mechanism of injury to the pelvis
- A traumatic injury to the sacro-iliac joint (SIJ) can occur from a vertical shear through the pelvis or femur for example in a heavy fall whilst playing sport or as a result of a direct blow to the lumbo-pelvic-hip region.
- Repetitive loading of the ligaments of either the SIJ or pubic symphysis can lead to local ligament injuries, usually in the presence of poor core stability and associated muscle imbalance of the lumbo-pelvic-hip region.
- Altered muscle patterning leads to overloading of other regional muscles due to compensatory attempts – this commonly leads to overuse tendon related injuries, some examples of which are:
- Repetitive hamstring muscle/tendon strains
- Gluteal tendon overload injuries
- Hip flexor muscle & tendon injuries (involving the psoas muscle)
- Ilio-tibial band (ITB) symptoms
- Adductor tendon and groin related problems
- Distinct hip joint pathology due to the muscle imbalances associated with different type of hip rotators, this may involve injuries of the tendons, ligaments, hip impingement and the joint capsule itself with hip labral tears.
- The pubic symphysis is often subjected to excessive and repetitive torsion forces in the activities associated with many kicking sports such as soccer, AFL, rugby. A condition previously referred to as “osteitis pubis” is such a condition which may result due to poor core stability in the lumbo-pelvic region and these torsion forces at the pubic symphysis.
- As already described pelvic/SIJ dysfunction contributing to knee problems resulting in patellofemoral joint overload and pain – one of the commonest of all sporting injuries!
- Continued overload of the lower limb kinetic chain with injuries arising from the lower leg and foot. It is a very common presentation for both the foot and pelvis to be simultaneously found to have dysfunction.
The treatment philosophy at Spinal Synergy Physiotherapy identifies and recognizes the synergy between the lumbo-pelvic-hip region to the function of the lower extremities with a key role for the SIJ and its impact on the function of other parts of the body. This approach addresses the entire body kinetic chain and appreciates the complex interaction of different parts of the body which although not causing pain directly none the less influence function of adjacent and distant areas.