This is the second in a series of patient stories where we describe the clinical presentation, diagnostic work-up and treatment of patients with SI joint dysfunction and pain from three 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 (adjacent segment degeneration). These patient scenarios are fictional and the clinical presentation and the response to treatment may not be representative of actual patients.
The second patient in our series is a 45 year old woman named Sarah who developed SI joint dysfunction after a slip and fall injury. Prior the injury Sarah was quite physically active and had no prior problems with her back, pelvis, hips or legs. Sarah remained a recreational tennis player after playing at a varsity level in college, practicing and playing matches at least 3-4 days per week. She had never experienced a significant injury and had no major health issues. She had no history of prior pregnancies.
Sarah slipped and fell on an icy sidewalk while walking her dog. She lost her balance and fell backwards landing on her left buttock. She landed on the bony prominence in her lower buttock called the ischial tuberosity. This is the bony prominence in the buttock (left and right) that is in contact with the chair when we sit. After Sarah’s fall, she was able to get up and walk back home. She felt tenderness in the area on which she had landed, and some soreness in the left side of her lower back and buttock. She applied an ice pack to her left lower buttock for 20 minutes and fell asleep.
The next morning, Sarah had significant difficulty getting out of bed because of pain in her lower back and buttock as well as a new area of pain in the area between the left side of her upper tailbone (sacrum) and her pelvic bone (ilium). She was taken to an urgent care center by a friend. She noticed it was also painful in her left lower pelvic region when she stood on her left leg to put on her pants and socks.
At the urgent care center, the physician asked her to point to the area of her worst pain and she pointed to the bony area in the left posterior buttock just below her spine. The physician stated this was called a positive “Fortin’s Test” and indicated that she was pointing to the area over her sacroiliac joint. Sarah also pointed out other areas of pain in her left lower back from her ribs to her pelvis, her left buttock out towards her lateral hip, the back and side of her thigh to just above her knee and to her left groin. She also pointed to the tender bruised area in the lower buttock over the left ischial tuberosity.
The physician asked her to rate her pain at her SI joint and she gave it a 5 at the lowest and 10 at the highest (on a scale from 0=no pain to 10=worst pain ever felt). The pain was worse when she tried to change positions or put weight on her left leg such as when walking or climbing stairs. She denied weakness, numbness or a lack of coordination in her legs. Her physician did a series of tests to assess nerve function in her legs. These tests included touching the skin to check sensation, testing her reflexes and testing the strength of certain muscles in her legs. The physician also did some tests where he was looking for signs of nerve tension indicative of nerve root compression. She did not have any positive findings.
The physician ordered x-rays of her lower back and pelvis which included her SI joint. All of these tests were negative. He recommended she continue icing, use anti-inflammatory medication, and rest for short intervals when her pain was severe. He told her she could work at her job as a biochemist but advised to her to take breaks from prolonged sitting or standing.
Her physician also recommended physical therapy. She made an appointment at her local clinic and went for an evaluation the next day. She noticed when she woke up the day of her appointment that her pain had increased in the left low back, buttock and groin. When she moved to get out of bed she had sharp pain in the sacroiliac joint area rated as a 10 out of 10. She struggled to get dressed, shower and get in and out of her car.
The physical therapist took her medical history and asked her questions about the fall. She relayed that she had to stand for long periods as a biochemist at work and enjoyed tennis. She shared that she was concerned she would not be able to perform her job and wondered if she would be able to return to tennis.
The physical therapist performed an individualized physical evaluation. Sarah had very different findings on examination than did our post-partum patient Barbara. Sarah’s findings included postural deviations (changes), limitations in her trunk and lower extremity (leg) mobility on her left side, a loss of strength in her left gluteal (buttock) muscles, myofascial (muscle and connective tissue) pain in her left lower back, buttock and groin, changes in her gait (walking) pattern, three out of five positive provocative tests for SI joint pain, and bad postural habits at work which were contributing to her increasing muscle and joint pain.
After 3 physical therapy visits which addressed the findings above, Sarah felt that her SI joint pain was not improving and shared this to her physical therapist. The physical therapist referred her on to an orthopedic surgeon who specialized in treating the lower back and SI joint. The orthopedic surgeon took her history and also performed provocative testing of the SI joint which revealed three out of five positive tests. He also reviewed her x-rays.
He recommended a stronger prescription anti-inflammatory and referred her to a pain management specialist in his office for a therapeutic injection into her SI joint. The pain management physician performed the same tests and agreed with the recommendation for a therapeutic injection. The pain physician injected both a local anesthetic (Marcaine) and a long acting medicine (steroid) into her SI joint in his office.
Sarah had 85% pain relief for three weeks after the injection and returned to physical therapy twice a week for four weeks. She noticed that most of her muscular pain in the left lower back and buttock areas as well as her groin were improving. Her left SI joint pain remained the same. She was not able to progress in her stabilization exercises, could not climb the stairs at work, and could not turn her torso with her tennis racquet in her hand without experiencing sharp pain in her left SI joint. She was able to start using an SI belt which did help the pain she experienced with her routine daily activities.
After four weeks she discontinued therapy as the physical therapist and she agreed that she had achieved as much as she could and was not improving. She did continue a home exercise program and self-managed techniques for pain relief. She returned to her pain management physician for another therapeutic SI joint injection which gave her 75% relief for 3 weeks. However, the pain in her left SI joint returned. She was able to get through her work day with use of an SI belt but was unable to go up and down stairs or return to tennis which was her social and recreational outlet. She shared with the surgeon that she was getting depressed.
Seven months after her initial injury, she returned to her orthopedic physician and asked if there were any additional treatment options for her left SI joint pain. He relayed that she could have an intervention called radiofrequency ablation or another steroid injection. She told the surgeon that she did not want a temporary solution. They then discussed the iFuse Implant System as an option to fuse her painful SI joint.
He explained that she need a diagnostic injection with only an anesthetic (no steroid) and would need to record her pain level several times during the day after the injection. She made an appointment with the pain management physician. He performed the injection under fluoroscopy (x-ray) to confirm that the material went into the joint. Her pain decreased from an 8/10 down to a 1/10 (on a 1-10 scale) for 6 hours after the injection. She was amazed that she was able to climb steps and could get in and out of bed, out of a chair and out of her car without using the SI belt with almost no pain.
She called her orthopedic surgeon and let him know that she wanted to proceed with the surgery. The orthopedists office had to submit her notes twice before her insurance would allow the surgery due to a few missing pieces of information. The reimbursement specialists from SI-BONE worked with the office to assure that her insurance company received the appropriate documentation. Her surgery was scheduled for the following week.
During her pre-operative visit she was given a hand out with activity guidelines for after the surgery. This handout explained how to move correctly and how to perform exercises to prevent blood clots and to maintain muscle strength and motion. After her surgery, she followed these guidelines. She used ice over the surgical area for pain relief and to minimize swelling. She avoided heavy lifting and deep squatting. Her surgeon recommended that she use a cane and only put 50% of her weight on her left leg.
Her physical therapist instructed her in how to correctly use the cane before she left the outpatient surgery center. An appointment was made for her to follow up with her physician 2 weeks later. One week after her surgery she was tempted not to use her cane because her left SI joint pain was gone but she remembered her physical therapist telling her it was important to use the cane until her walking pattern back was back to normal. She returned to her physician two weeks after surgery. He told her she was healing well and that she could discontinue using the cane and should increase her walking as tolerated. He referred her back to her physical therapist for a re-evaluation and additional strengthening to begin four weeks after her surgery.
The physical therapist performed a full re-evaluation and found that she still had some areas that needed attention. Sarah had issues with her posture, trunk and lower extremity (leg) range of motion, core strength and her gait (walking pattern). Her complaints of SI joint pain and the positive tests for SI joint pain had resolved. She also had some residual soft tissue tightness and tenderness in he left quadratus lumborum (lower back muscles) and the deep posterior hip muscles including the piriformis.
The therapist prepared a treatment plan to address these findings and also provided instruction in postural alignment, positioning and body mechanics. Soft tissue mobilization was performed on the painful muscles in the left lower back and left posterior hip and the tenderness resolved. They worked on Sarah’s walking pattern (gait) to eliminate some problems that she had developed as an attempt to unload her SI joint during walking. Sarah also received instruction on core muscle strengthening including contraction of her abdominal and her pelvic floor musculature during exercise. She eventually incorporated these techniques into her tennis swing and was able to return to playing recreationally.
Sarah followed up with her surgeon after 1 month of therapy (two months after surgery). She reported to the surgeon that she had returned to normal daily activities without pain and that she was even able to play tennis for short periods. At her 6 month surgical follow up, Sarah reported she was back to competitive tennis and due to all of the advanced core strengthening she had done in physical therapy, her serve and forehand were now much stronger.