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Submitted by: Joseph W. Bergeron, MD
Sitting on a toilet is a relaxing experience, usually. It wasn’t for the
first sacroiliac injury I ever treated. She was a rotund young lady in
her mid-twenties. While sitting on a commode in a luxury hotel, it came
unbolted from the wall whereupon she and the bowl landed on the floor.
She sustained a left sacroiliac strain from this, which unfortunately
led to chronic sacroiliac pain, sacroiliitis. She subsequently had a
significant (perhaps excessive) course of evaluation, treatment,
disability claims and litigation. I distinctly recall feeling sorry for
that hotel chain, let alone myself and the other physicians from whom
she sought care.
Imposter? Better said, the differential diagnosis of medical problems or
injuries than can cause similar signs and symptoms is extensive. This is
because the locations of pain and radiation can differ among patients,
and vary for a single patient. Inflammatory and seronegative
arthropathies, lumbar radiculitis, degenerative disc disease,
spondylosis, spondylolysis, sacral fracture, metastatic disease, pelvic
pain, (e.g., uterine fibroids), can all have similar presenting
symptoms. It can accompany mechanical imbalance, such as that seen with
leg length discrepancies, scoliosis, spasticity, etc. Because symptoms
are obscure and diagnosis challenging, expensive testing is usually
non-diagnostic and ill-defined treatment often unsuccessful. Patients
often have had extensive evaluations, MRI’s, EMG’s, etc, without
clarification of the problem.
Sacroiliac strain/dysfunction should be in the mind of the examiner for
any patient with sciatica, i.e. lumbar pain and leg pain. One of my
favorite teachers in medical school, someone very good at physical
examination, told us one day, “you can see the same things I see, if you
look for them.” If not considered, the diagnosis will be missed. There
will usually be a historical event, perhaps repetitive, of differential
rotational force across the pelvis. Pertinent negatives should exclude
other, non-occupational, medical conditions that can imitate the same
symptoms. I’ve listed some of those conditions I’ve seen in practice,
above. On exam, specific tenderness over the sacroiliac joint it usually
(not always) present, and Patrick and Gaenslen exam maneuvers can be
supportive in the empiric diagnosis. Neurological, musculoskeletal,
abdominal examinations should be negative. A fluoroscopically guided
diagnostic injection of the sacroiliac joint provides the best
diagnostic confirmation.
Special testing should include, lumbar X-rays to include oblique and
flexion/extension views, lumbar MRI, and rheumatologic laboratories.
These are to exclude vertebral compression fracture, spondylolisthesis,
spondylosis, disc pathology, instability, and rheumatologic conditions.
If complete pain relief is noted after an injection (a diagnostic
response) is seen, but with rapid return of significant pain the same or
next day, a bone scan or pelvic MR should be considered to exclude a
pelvic/sacral fracture or other destructive pathology, if warranted by
history or laboratory abnormalities.
Fluoroscopically guided sacroiliac injections provide diagnostic and
potentially therapeutic benefit. With direct visualization, the joint
can be anesthetized by injection, plus corticosteroid can be delivered
simultaneously. Complete or near complete resolution of pain
immediately, is considered diagnostic. Fluoroscopy is the only reliable
way to inject the joint, as it provides real time confirmation of needle
location by direct visualization. The sacroiliac joint can only be
entered in the inferior third of the visualized joint on X-ray due to
the many ligamentous attachments (see figure). This is very difficult to
palpate except in the very thin. While blind injections can sometimes be
effective, a recent study using post injection CT, suggests an 80%
likelihood of missing the joint by blind injection. This is clearly
unacceptable in the management of personal or occupational injuries.
Treatment should include non-opiate analgesics, physical therapies for
pelvic stabilization (preferably with a therapist having an interest in
this type of injury), and sacroiliac supports can be useful for some
patients. Work restrictions should limit bending at the waist,
squatting, and climbing. Naturally, this is amended based on clinical
progress and the patient’s occupation. A functional capacity evaluation
may be necessary if there are concerns as to whether the patient is able
to match his/her job description. Maximal medical improvement can be
reached in four to six weeks, if not sooner, in my experience. If there
are persisting symptoms, a small permanent partial impairment rating of
one to three percent is not unreasonable.
While in college, I strained my right sacroiliac joint running up a
staircase, skipping steps with each stride. It was extremely painful. I
could barely walk on it for several days. Thankfully, it resolved with
self-treatment and exercise. I wish I could say this is always the case.
My experience is that the natural history of the injury is highly
variable and essentially patient specific. Some people get over it, some
get better, and some don’t.
Sacroiliitis is in part a diagnosis of exclusion. If suggested by
history, exam, and in the absence of an obvious source for the patient’s
symptoms otherwise, a diagnostic sacroiliac injection should be
considered. If the diagnosis is confirmed, reasonable treatment can be
completed expeditiously. If the injection is non-diagnostic, it’s on to
the next item on your differential. Arriving at the correct diagnosis is
the first step to successful treatment.
I cannot forget the first patient I treated with post-traumatic
sacroiliitis. Nor can I forget my own experience with sacroiliac pain.
One thing is sure. Whenever I go to a public restroom, I first look to
make sure the commode is securely fastened to the floor.
Dr. Bergeron is board certified in Physical Medicine and Rehabilitation
and Pain Medicine. He has recently relocated from Terre Haute to
Indianapolis.
New Location:
Joseph W. Bergeron, M.D.
9292 N. Meridian St., suite 111
Indianapolis, IN 46260
Phone (317) 705-0909
Fax (317) 705-0910
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