Excellent article on SI Joint Dysfucntion
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SI Joint Instability, Pelvic Instability and Dysfunction:Cause of Much Pain and Dysfunction
One cause of SI joint dysfunction stems from instability of the SI joint. Many experts feel that SI joint pain is a component of a larger problem of pelvic instability(1). Pelvic instability has traditionally been underappreciated as a cause of low back pain, buttock pain, groin pain, and leg pain. Physical therapists and doctors of osteopathic medicine have been teaching these concepts for years but only relatively recently has this dissemination of knowledge trended towards mainstream thinking among medical doctors.
The SI joint complex (the SI joint and its associated ligaments) is the major support structure of the pelvic ring and is the strongest ligament complex in the body. The complex consists of interosseous sacroiliac ligaments, iliolumbar ligaments, posterior sacroiliac ligaments, and the sacrotuberous and sacrospinous ligaments. The SI joints are two of the three joints involved in the stability of the pelvic ring. The pelvic ring is the meeting place of the force vectors from the upper body and the lower extremities. The third joint in the pelvic ring is the pubis symphysis. Pelvic instability causes pelvic rotation which can also cause twisting of the pubis symphysis. Coupling this with its anterior location appears to provide an explanation as to why patients with SI joint instability can also experience anterior groin pain. Anecdotal evidence for this is seen when patients undergo a successful SI joint intra-articular injection relieving all of their posterior back, buttock, and leg symptoms but the patient still has groin pain. Groin pain is almost never eliminated by SI joint injections unless pelvic symmetry is corrected.
If the SI joints are unstable, it can lead to significant pain and discomfort over the SI joints as well as numerous referred areas. If an individual affected by SI joint pain has pain only over his or her SI joint, he/she should be considered lucky. Most often SI joint instability causes unnatural strain on the entire low back and pelvic region causing a sometimes confusing clinical picture. Pain referral patterns of SI joint pain are often confused with L5 or S1 radiculitis or radiculopathies.
Referral patterns of SI joint dysfunction (2)
SI joint dysfunction often presents with a confusing clinical presentation.
1. Buttock pain 94% ( Yes I have)
2. Lower lumbar pain 74%, ( Yes, some)
3. Lower extremity pain 50%, with 28% of these lower extremity pains going distal to the knee
4. Pain goes all the way into the foot 13%. Younger patients are more likely to refer pain distal to the knee. ( Absolutely, pain in legs for over 2 years)
5. Groin pain 14%. ( YES)
Most patients with SI joint instability also experience pain over the buttock region due to secondary muscle spasm of the gluteus muscles and piriformis complex. Lower extremity symptoms are explained by the piriformis muscles natural tendency to spasm or tighten over the sciatic nerve whenever the SI joint is out of alignment. This spasm of gluteus and piriformis muscles can cause a mechanical crowding or impingement of the sciatic nerve as it exits just below the SI joint (see figure 1. note the intimate association of the piriformis muscle, SI joint, and sciatic nerve). Patients often complain of buttock pain and radiation of pain down to the knee and even down to the foot. Not all back pain and leg pains are due to a pinched a nerve from an intervertebral disk herniation. SI joint dysfunction very closely mimics S1 or L5 radiculitis' or radiculopathies because of the above described sciatic nerve irritation or impingement
Groin pain and abdominal pain are not uncommon with SI joint instability. Often times the groin pain is mistaken as a urologic problem like prostatitis, genitofemoral neuralgia, or sterile epidydymitis(1). This is likely either due to unnatural tension on the nerves and ligaments around the pubis symphysis or actual impingement of the pudendal nerve which lies between the sacrospinous ligament and sacrotuberous ligament. The distance between these two ligaments abruptly narrows when the Ilium and sacrum are out of alignment i.e. SI joint instability.
The typical history of SI joint dysfunction consists of lateral or bilateral low back pain almost always below the pelvic rim. Pain can also radiate into the hip, groin, pelvis, leg, and foot. The most common location of pain is in the buttock with pain extending down to the knee. Females are much more affected than males though the ratio is unclear. The mechanism of injury is a continuum from completely atraumatic events to more obvious trauma like motor vehicle accidents, childbirth, or falls. A little over one third of failed back surgery patients suffer from SI joint dysfunction. Patients must change positions frequently to avoid pain. This is called “Theater Party Cocktail Syndrome”. Patient's legs can also feel like they're going to give out, but with objective testing of motor strength, no dysfunction is found. This is called a “Slipping Crutch syndrome”. Patients usually have a difficult time sleeping and getting out of bed in the morning can be painful. Continued movement after waking up tends to improve the pain.
Another treatment for SI joint pain is Prolotherapy. Prolotherapy works by stimulating an inflammatory cascade which leads to fibroblastic activity thereby strengthening the entheses of ligaments and tendons.
Posted on 12/19/10, 09:05 am
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