This is the first in a series of cases where we will describe the clinical presentation, diagnostic work-up and treatment of three patients who have SI joint dysfunction and pain from different causes. The first patient has SI joint dysfunction that developed during pregnancy and continued into the post-partum period. The second patient has SI joint dysfunction secondary to trauma and the third patient developed SI joint dysfunction after lumbar spine surgery (SI joint degeneration). These patient stories are fictional and the clinical presentation and response to treatment may not be representative of actual patients.
The first patient in our series is a 35 year old woman named Barbara. She has ongoing SI joint pain which began during her first pregnancy and worsened with her two subsequent pregnancies. During the 12th week of her first pregnancy, Barbara began to have pain in the right buttock area that extended to the top of her tailbone. She was able to localize the pain to this area for her OB/GYN, rating it an 8 at worst and a 2 at best on a 0 to 10 scale. (This is a typical way that physicians describe pain ranging from 0 (no pain) to 10 being the worst pain imaginable.) Barbara reported to her OB/GYN that she had no past history of pain in her low back, hips or pelvis. Barbara noticed that the pain increased with physical activities such as walking and going up and down stairs. She also had difficulty sitting and standing for long periods of time. The pain gradually worsened through the remainder of her pregnancy and was severe in the immediate post-partum period. The pain was a little better by 6 months post-delivery. Barbara experienced similar painful symptoms with her subsequent two pregnancies. With each pregnancy the symptoms were more severe and lasted longer after delivery. After her third pregnancy, the pain never really got better. Now she complains of progressively more severe functional limitations with sitting, standing, walking, and lying on the involved side.
Barbara was initially perplexed because she had gained only a few pounds during her first trimester. She had always been an active person, exercised regularly and considered herself to be in good shape. She first noticed pain in the right buttock area and soon thereafter the pain began to spread (radiate) down from the right buttock into the right posterior thigh region. The pain was more noticeable when she tried to sleep on her right side, when she changed positions in the middle of the night and also during the day when she got in and out of bed, stood up from a chair or bent and twisted to get into or out of her car.
She described the pain as a sharp sensation in the right buttock area when she changed positions. At other times she reported it as more of a dull ache in that area which spread from her right buttock. She states that she was no longer able to walk for exercise. She relays that she feels like her right leg is going to “give out” when she gets out of a chair and starts walking but does not have a sense of weakness or any numbness or tingling in her right leg. She notes that she feels better when she walks with her right leg turned slightly outwards and if she takes smaller steps. She also reports that she has pain in the same area in her right sacral region when she attempts to have intercourse. After her OB/GYN exam, she had sharp pain when trying to get up off of the table after having her legs supported by the stirrups.
Barbara did not seek treatment until after her third delivery, as she assumed that pregnancy was associated with pain. She now appreciates that her pain is not improving and that it is actually worsening over time. Her OB/GYN referred her to a physical therapist that specializes in treating pregnancy related low back and pelvic pain.
Her physical therapist takes a thorough history and performs an individualized evaluation that includes evaluation of her:
- Trunk and Lower Extremity (leg) Range of Motion
- Strength of her trunk including her abdominals, lower extremities and pelvic floor
- Neurological examination including strength and sensation testing, reflexes, and neural tension tests
- Mobility of the joints in her lower back, hips, knees and ankles
- Mobility of the soft tissues near the SI joint and of the tissues that connect to the pelvic region directly and indirectly
- Gait (walking) pattern for deviations
- Postural habits and functional movement patterns
- SI joint pain with Provocative Testing (clinical tests that when 3/5 are positive indicate the joint is likely to be the source of pain)
- SI joint with other special tests including active straight leg raise test
- Hip joint with range of motion testing, the hip scour and hip impingement tests
The physical therapist documented the following findings:
Posture: Within normal limits with exception of an increased anterior (forward) tilt of her pelvis with an increased lumbar lordosis (lower back) curve.
Trunk Range of Motion: The patient had full range of motion with exception of limited forward bending with her fingertips only to the knees with complaints of pain in her right lower back and limited left lateral bending with fingertips 3 inches above the knee with complaints of pain in her right lower back.
Lower Extremity Range of Motion: Patient has normal range of motion of both of her lower extremities (hip, knee and ankle joints) with exception of right hip extension which was lacking 20 degrees and her right quadriceps (thigh muscle) was tight/short indicated by a hip angle of 0 degrees while lying on the table with a knee angle of 120 degrees. She also has limitation in right hip internal rotation (inward rotation) to 10 degrees with 35 degrees being normal.
Strength: The patient has normal strength throughout her lower extremities and trunk musculature with exception of her right hip extensors (gluteals) which show decreased strength of 4 out of a possible 5 (or 4/5) and a muscle called her gluteus medius (pelvic balance muscle) which rated a 4/5. She also showed latissimus dorsi strength which was limited on the left side at 4/5. Her abdominal strength rated a 4/5 and her pelvic floor muscle strength rated a 3+/5. She has no detectable separation of her abdominal muscles at the midline which is called a diastasis recti which may be associated with pregnancy
*** The gluteal and latissimus muscles are both important stabilizers of the SI joint as they cross over the joint and provide active stability or “force closure” to the SI joint. The pelvic floor and the abdominal muscles are important components of the core muscles that are deep muscles that need to contract with full strength and good timing to provide stability of the SI joint.
Neurological Testing: Patient has normal deep tendon reflexes throughout both lower extremities and normal sensory testing. She also has a negative passive straight leg raise and dural tension tests which are tests for nerve irritation.
Joint Mobility: The patient has normal measurement of joint mobility in her bilateral ankles, hips, knees and lumbar spine with exception of limited hip internal rotation on the right side. This was determined to be a muscular limitation secondary to tightness of the external hip rotator muscles as further testing of her hip joint mobility revealed no significant limitations.
Soft Tissue Mobility : The patient had normal soft tissue mobility and no pain with palpation of the muscles of her trunk, pelvic region and abdominal musculature with exception of soft tissue tightness and pain to palpation of her right quadratus lumborum (a muscle that extends from the right lower ribs to the right pelvic bone), her right hip external rotators including her piriformis which were very tender and had multiple tender areas, and she also had tenderness with palpation of the ligaments (non-elastic structures which connect bones and support joints) in the area supporting the connection between the right sacrum (tailbone) and right Ilium (pelvic bone).
Gait Pattern: The patient has an abnormal walking (gait) pattern. When she puts weight fully on the right leg she has pain, which is called an antalgic pattern. She also holds her right leg slightly turned out (externally rotated) at the hip because this feels less painful and she takes a shorter step on the right side due to the pain.
Postural Habits and Functional Movement Patterns: The patient was asked about her daily activities and it was discovered that she stands the majority of the time with her weight on her right leg with her toddler on her right hip, she sleeps on her left side without support and she pulls her right leg up into flexion, external rotation (outer rotation) and abduction (positioned out to the side). She twists to the left often to unload her dishwasher, her washing machine, iron, and get her toddler’s car seat out of the car with her right leg fixed to the ground and notes pain in her right SI joint region and into her buttock with all of these activities.
SI Joint Special Tests: Barbara has a positive active straight leg raise (ASLR) test on the right indicating that she has decreased functional stability of the right SI joint and a negative test on the left. She then had provocative testing of her bilateral SI joints and she had 3 of 5 positive tests including tests called the Distraction test, the Thigh Thrust test and FABER test. The physical therapist decided to discontinue provocative testing after finding the positive tests were increasing Barbara’s SI joint pain..
Because Barbara had limited hip internal rotation on the right, the physical therapist decided to do an additional clinical test to rule out hip conditions such as arthritis called the hip scour test and this was negative.
Based on these findings, the therapist came up with an individualized treatment plan to address the findings above including:
Patient education regarding postural alignment, positioning and body mechanics
Patient was advised to stand with weight equally distributed on both legs with knees slightly bent to activate her muscles rather than put additional strain in her joint structures, avoid carrying her children on her right hip and provided recommendations to sleep with a small pillow under her waist and a second pillow between her knees in side lying or when supine to place a pillow under her knees. She was also advised to substitute twisting to the left with her right leg fixed during daily activities with moving her entire body or to rotate on the ball of her right foot versus with her foot planted to allow hip motion during twisting.
Manual Treatment: Manual joint techniques to right ilium and sacrum to inhibit and decrease tension from short and tense right quadriceps and quadratus lumborum. Soft tissue mobilization and trigger point release techniques to her right quadratus lumborum and right hip external rotators and instruction in self soft tissue mobilization techniques for use at home. The physical therapist performed contract/relax manual stretches to patient’s short quadriceps and quadratus lumborum followed by instruction in self-stretching with the exercises to be performed at home.
Instruction in use of an SI belt. Patient was instructed in proper use of an SI belt. She was advised to apply the belt daily prior to performing activities that typically recreate her pain.
Gait Training: Patient was instructed to avoid excessive hip external rotation and hip hiking on the right and to allow for full stride within limits of her pain. She was able to do this with use of her SI belt.
Strengthening: Patient was instructed in identification of and engagement of her transverse rectus abdominus and her pelvic floor musculature. She was given progressive, supervised strengthening exercises for both muscles and then was instructed in how to engage the muscles before position changes and activities of daily living which typically cause pain. She was also instructed in strengthening exercises for the latissimus dorsi and gluteus muscles.
Barbara attended therapy two times a week for 4 weeks and then once a week for an additional 4 weeks. She had a final follow up visit 4 weeks later. At the time of discharge she had significant improvement of most of her positive objective findings including:
Elimination of postural deviations and gait deviations, normal trunk and lower extremity range of motion and increased abdominal, latissimus dorsi and pelvic floor muscle strength to within normal limits. She had improvement of myofascial pain in the affected muscles. Barbara reported that her pain had decreased to 6/10 as a maximum and the pain was only occurring 25% as often as it had previously and this occurred after prolonged sitting or lying supine and with prolonged walking. She reported that she had increased pain with shopping or standing for long periods and she required use of an SI belt with these activities. She stated she was happy with results of treatment but discouraged by her continuing pain and need to rely on her SI belt.
Barbara’s physical therapist knew an orthopedic surgeon who specialized in treatment of the lower back including the SI joint. Barbara scheduled a visit with this physician who took a thorough history and performed a physical examination that included provocative testing of her SI joints. On examination she was found to have 3 of 5 positive provocative tests. As she had completed a comprehensive physical therapy program and had not achieved pain free function, he referred her to a pain management physician for a diagnostic SI joint injection to confirm that the SI joint was the source of her pain.
The pain management physician performed a history and physical examination. He then performed a diagnostic SI joint injection using a short acting local anesthetic. He performed the injection under fluoroscopy using injectable contrast to assure that the solution he was injecting went into the joint. Barbara had immediate pain reduction to a 1/10 and was able to perform all of her functional activities without pain for the next two hours. The pain returned quickly, but she understood that a diagnostic block is performed to see what level of pain relief a patient experiences with the local anesthetic and that no long acting medication (like steroids) was included in the injection.
Two weeks later the pain management physician performed a therapeutic injection. This time the pain physician injected both a local anesthetic (Marcaine) and a long acting medicine (steroid) into her SI joint under fluoroscopic guidance. Barbara had approximately 75% pain relief for three weeks after the injection. The pain returned to a level of 7/10 eight weeks later and she had to start using the SI belt. She decided to visit the pain management physician. She explained that she was uncomfortable and frustrated with her level of pain relief and the continued functional limitations. He recommended that she return to the orthopedic surgeon to discuss additional treatment options, including surgery.
When she returned to clinic the orthopedic surgeon discussed her options and they agreed that she would be a good candidate for a minimally invasive surgery to fuse her SI joint with an iFuse Implant™. She had history and physical examination findings consistent with the published patient selection guidelines for SI joint dysfunction due to SI joint disruption.
She returned for her pre-operative appointment with her surgeon who had carefully documented her case and confirmed that she met the NASS (North American Spine Society) recommendations required by her insurance company for the surgery to be covered. She underwent surgery three weeks later to place three triangular titanium implants across her SI joint through a small incision in a muscle called her gluteus medius. She was given post-operative guidelines and felt prepared for her post-operative course.
She was advised by her surgeon to use crutches for 3 weeks after her surgery and to only put half of her weight on her right leg. The surgeon stressed she use a heel-toe gait and push off of her right toe to avoid hiking her hip and setting off pain in her right lower back muscles. She was advised to keep pressure and ice on her incision for a day or two after the surgery and to avoid laying on the operated side or sitting for too long. She followed the exercise program in her guidelines handout to prevent loss of strength and/or range of motion from being less active and to prevent blood clots which she was told is standard protocol after most orthopedic surgeries.
Barbara initially had a bit of soreness at the surgical site but was amazed that she had complete elimination of pain at her SI joint with all of her previously painful activities. She did not feel that she had to use the crutches for pain relief but was advised by the PT at the surgery center to continue to use them until her post-operative follow up visit to keep her walking pattern as normal as possible and allow muscles that were not firing properly before her surgery to get used to working again. She still noticed some soreness in her right buttock muscle.
At her first post-operative appointment, her surgeon saw that she had a well healed incision and asked her typical pain level and if she had experienced any loss of balance. Finding she had elimination of pain at her SI joint and no reports of loss of balance he advised her to discontinue the use of her crutches and referred her to physical therapy to address any underlying/remaining musculoskeletal issues. She was set up to visit her surgeon for an additional follow up appointment 6 weeks later.
Barbara made an appointment with her physical therapist who was encouraged that Barbara had remained compliant with her home exercise program after her surgery. Barbara received a thorough evaluation as she had before but had a significant decrease in the number of objective findings. Barbara’s only remaining complaint was some tenderness in her right buttock which was intermittent and rated a 3-5/10 and general fatigue as she had been less active for the last several years due to the pain.
The only objective findings found by her physical therapist upon evaluation included:
Strength: Decreased abdominal strength rated 4/5. Decreased gluteus medius strength on the right at 4/5.
Range of Motion: Hip internal rotation limited to 10 degrees on the right (normal 35 degrees)
Palpation: Patient had tenderness to palpation and trigger points noted in her right hip external rotators including her right piriformis.
Gait: Patient has continuing excessive hip external rotation during the gait cycle and a shortened stride length on the right
Cardiovascular Findings: Patient had a resting HR of 86.
Barbara’s course of physical therapy consisted on 1 visit per week for 4 weeks followed by 1 visit 4 weeks later and a discharge visit an additional 4 weeks later. Her treatment consisted of:
- Review of proper body mechanics, postural alignment and positioning with ADL’s
- Strengthening for her right gluteus medius and supervised progression of her abdominal strengthening/stabilization program
- Stretching of her right hip external rotators manually by the therapist in the clinic and independently at home assuring the patient maintained neutral lumbopelvic alignment.
- Soft tissue mobilization/ myofascial release techniques for the painful right hip external rotators
- Gait training to reduce deviations
- Instruction in cardiovascular reconditioning using a recumbent bike with lumbar support in the clinic and at home with instruction in monitoring of heart rate.
At Barbara’s discharge visit from physical therapy, objective findings were absent and she reported elimination of remaining symptoms including her fatigue. She had achieved the functional goals she had prioritized with her physical therapist. At her last follow up appointment with her surgeon she stated that she had full pain free function and was able to enjoy her new more active lifestyle with her children.
The iFuse Implant System is intended for sacroiliac fusion for conditions including sacroiliac joint dysfunction that is a direct result of sacroiliac joint disruption and degenerative sacroiliitis. This includes conditions whose symptoms began during pregnancy or in the peripartum period and have persisted postpartum for more than 6 months. There are potential risks associated with the iFuse Implant System. It may not be appropriate for all patients and all patients may not benefit. For information about the risks, visit: www.si-bone.com/risks