Diagnosing Sacroiliac Joint Pain Is Challenging - Everything You Need To Know - Dr. Nabil Ebraheim
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- Опубліковано 21 вер 2024
- Dr. Ebraheim’s educational animated video describes the condition of SI joint pain - Why is the diagnosis of SI joint pain challenging?
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We all know that low back pain is very common. The sacroiliac (SI) joint is a major source of low back pain because it is responsible for approximately 22% of all low back pain and about 40% in patients with lower spine fusion. The problem is that the pain originating from the SI joint is usually attributed to other sources such as the spine and the hip. Patients with low back pain spend months or years in treatment without correct diagnosis. Patient with chronic low back pain and this patient is not improving with treatment, it is important to look at the SI joint as the source of the low back pain. So why is diagnosing the SI joint unique and why is there confusion about diagnosing SI joint pain? Why will the patients go to see multiple health care providers and get multiple diagnosis with many images and MRIs? The MRIs alone could give false positives about the intervertebral disc condition. And why are we missing the real pain generator, which is the SI joint. The truth is that the SI joint does not have a known cause for the pain. Diagnosing the SI joint pain is challenging. There is no radiological study or a clinical exam that can give us a reliable diagnosis. The SI joint is less recognized as a cause of low back pain. This is not something the MRI, the x-ray or the CT scan can show clearly. Up to 25% of asymptomatic patients over the age of 50 years old will show abnormal SI joints in the x-ray. It is known that the articular surface of the Si joint changes with age. The synovial surface begins to degenerate by the age of 50 and closure of the SI joint is common in men after the age of 50. When there is a previous lumbar fusion check the x-rays carefully. Make sure that the hardware is stable. There is a wide variability in the clinical presentation from localized pain to tenderness around the SI joint, to radiating pain that looks like sciatica. The Si joint pain overlaps with spine pain and hip pain. The Si joint pain can be similar to facet joint pain, sciatica, disc herniation, or discogenic pain. SI joint pain can mimic sciatica, mimicking disc herniation. The SI joint must be part of low back pain evaluation. Make sure you have a high index of suspicion for every patient with low back pain. Make sure that the patient’s description and location of the symptoms is clear to you. Ask the patient “where is the maximum area of pain?” The Fortin finger test is confirmed when the patient points to the area of the pain by the finger just medial and inferior to the PSIS. Where does it hurt? If the patient points with the finger below the L5 level, then this is the Fortin finger test and it is suggestive of SI joint pain. Versus if the patient places a hand above the L5 level. Then this is probably low back pain due to spine causes especially if the patient’s pain is in the midline. Placement of a finger describes the pain over the painful area, is to the side, at, or below the PSIS. The pain is usually below L5 level in majority of cases. After we find the location of the pain by the Fortin test, tell the patient we are going to do examinations to provoke the symptoms because we are going to try to find the cause of the pain. Ask patient to tell you if it is the same pain or different pain. The whole idea is that shear of the SI joint reproduces the pain. With three or more positive provocative tests, we will need further investigation to confirm the diagnosis. The compression test and the thigh thrust test are considered to be the most valuable tests. Recommend the injection when the patient has a positive history, positive Fortin finger test, positive provocative tests, negative lumbar and hip examination and negative x-rays. Use the injection to confirm the history and the physical examination. Use ultrasound or fluoroscopy for the injection. Some problems with injection. Two thirds of patients have 50% pain reduction for about six weeks. Value of injection is lower in patients with spine fusion. Do not inject more than three times within six months or four times in one year. If you have 75% pain improvement is a positive test which means that SI joint is the pain generator. If you have 50-75% improvement, then this is an equivocal test and then you repeat the injection because the patient may have multiple pain generators. If you have minimal or no response, then this is a negative test and the SI joint is probably not the source of the pain. Treatment of SI joint dysfunction is usually conservative without surgery. Surgery is done by Si joint fusion - leads to symptomatic improvement when the SI joint is the primary pain generator. The fusion will give the patient significant improvement in pain and disability and improving the quality of life at 2 years.
I love these educational videos! Thank you, Dr. Ebraheim
Alhamdulillah, these is so true Doctor Nabil. I've come to realize my long problem of the lowerback pain. Going for the 6months injection. God Bless.
This doctor is so understanding ❤
Honestly the best explanation on UA-cam. Thank you
I agree w Ericcson. Piriformis syndrome and hypermobile SIJD.
There are other manual tests that PT's use to determine SIJD.
A 6 week SIJD Conservative program is is beneficial for approximately 80% of patients with SIJD. This research was presented at the Australian SIJD conference by Vicki Sims PT.
Her clinic is in Gainesville, Ga, USA. She and her staff see SIJD patients from across the globe. And are very successful w differential diagnosis and treatment .
Thank you Dr. for this informative talk. Many Dr.'s do not believe the SI can move but I am here to tell you I've seen it and performed the mobilization that are successful.
Thank you,
Gail Whonic P.T.
Thank you for a very thorough explanation! Definitely helpful!
Thank you Dr. Ebraheim for the comprehensive explanation! Your expertise is greatly appreciated!!! 🙏☺
Glad it was helpful! and thank you for the gift
As usual very exceptional explanation thank you Dr Nabil and hoping for more and more videos in a shorter interval of time :)
Seriously what a brilliant video
When people sit their iliopsoas shortens and over time it becomes chronically short which pulls on some lower vertebrae and causes low back pain. It happens to me. Stretching it helps. Also core strengthening.
Thank you very much.
Worth mentioning piriformis syndrom as a differtial diagnosis.
In chronic piriformis syndrome you will also have SIJ problems.
So helpful and informative.
Here is the transcript notes of the video
00:04
why diagnosing sacroiliac joint pain is challenging we all know that low back pain is very common the sacroiliac joint is a major source of low back pain it is responsible for
00:21
approximately 22 of all low back pain and about 40 in patients with lower spine fusion the problem is pain originating from the sacroiliac joint is usually unappreciated under diagnosed and
00:40
misunderstood and this pain is usually attributed to other sources such as the spine and the hip patients experiencing low back pain can spend months or even years in treatment
00:59
without the correct diagnosis if you have a patient with chronic low back pain and this patient is not improving with treatment it is important to look at the sacroiliac joint as the source of the low back pain
01:18
so why is the sacroiliac joint unique and why is there confusion about diagnosing sacroiliac joint pain why will the patients go to see multiple health care providers and get multiple diagnoses with many images and mris
01:40
the mris alone may not be very helpful it could give us false positives about the intervertebral disc condition and why we're missing the real pain generator which is the sacroiliac joint the truth is this sacroiliac joint does
02:02
not have a known cause for the pain there is no typical clinical history and typical physical exam findings or imaging studies that exist and help the clinician in making a reliable diagnosis the truth is the sacroiliac joint is an
02:24
important joint it transfers the force and the load from the spine to the legs through the hips the circular joint is 20 times more vulnerable to axial overloading than the lumbar spine
02:43
and for people that want to know where the sacroiliac joint this is a simple explanation this is the spine the lower part of the spine is called the sacrum
02:58
and this is the pelvis the connection between the sacrum and the pelvis is called the sacroiliac joint the sacroiliac joint has unique anatomical characteristics
03:16
the joint surfaces are irregular it has strong ligaments surrounded by strong muscles for support and destabilization of the joint the posterior superior iliac spine is rich with posterior sacral network of
03:37
nerves and close to the sacroiliac joint there's a lot of nerves including the lumbosacral plexus the origin of the sciatic nerve because the nerves run around the sacroiliac joint the patient can present
03:55
with sciatica like pain with buttock pain radiating down the thigh and the leg the lower part of the sacroiliac joint is synovial which can be inflamed and inflamed synovial fluid can leak outside
04:11
the joint and irritate this surrounding nerves because of its anatomy the cycloalia joint is subjected to severe mechanical stress what are the causes or the predisposing
04:27
factors of sacroiliac joint pain the cause of the pain is usually idiopathic with multiple risk factors existing including prior lower lumbar spine fusion more than three levels eighty percent of the patients will give
04:46
a history of a specific trauma usually a twisting injury repetitive low impact activities such as jogging pregnancy and closing spondylitis
05:03
if you suspected get hla b27 scoliosis leg length discrepancy there is really no specific cause for the sacroiliac joint pain the cause of the sacroiliac joint pain
05:22
is usually difficult to determine some people believe it is a mechanical dysfunction usually the sacroiliac joint allows for minimal movement excessive or abnormal movement can cause
05:39
dysfunction of the sacroiliac joint in stability and pain it can be this small movement of the sacroiliac joint which is less than 1.6 millimeter of translation and less than four degrees of angulation causing that
05:57
amount of pain diagnosing the sacroiliac joint pain is not easy in fact it is challenging there is no radiological study or a clinical exam that can give us a reliable diagnosis
06:16
the sacroiliac joint is less recognized as a cause of low back pain because usually it doesn't show any abnormality geographically this is not something that the mri the x-ray or the ct scan can show clearly
06:35
up to 25 percent of asymptomatic patients over the age of 50 years old will show abnormal sacroiliac joints in the x-ray it is known the articular surface changed with age the synovial surface begins to degenerate by the age
06:54
of 50 and closure of the side joint is common in men after the age of 50. although the patient may have some mri findings of disk changes and this may throw the physician off when there is a previous lumbar fusion
07:15
check the x-rays carefully make sure that the hardware is stable with no hardware failure or loosening and no non-union or adjacent segment instability there is a wide variability in the
07:32
clinical presentation from localized pain to tenderness around the sacroiliac joint to radiating pain that looks like sciatica the sacroiliac joint pain overlaps with spine pain and hip pain
07:52
the fact that the patient may have more than one pain generator and they should be differential diagnosis with spine conditions and with hip conditions this inside joint pain can be similar to facet joint pain sciatica disc
08:09
herniation or discogenic pain sacroiliac joint pain can cause sciatica mimicking disc herniation the cigarette joint must be part of low back pain evaluation when the pain of the sacroiliac joint
08:27
affects the groin it overlaps the hip joint pain you must identify the primary source of the pain in order to achieve a successful clinical outcome in reality in addition to doing spine
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Can you create new video all what we need to know about multifidus please? Thank you Dr. Ibrahim
Thanks
Excellent video - I have had chronic back pain for over 25 years as I work on fours as a professional gardener, due to back injury many years ago. Is it possible to to have problem with both sides as I have pain over both si joints?
Excellent!!!
I thinl I got this based on the symptoms, in 2 days I will do MRI I will make sure Lumbar negative
1.25 speed recommended
thank
💯
Thank you very much.
I have had leg pain for 6 years and for the last 2 years I started to feel back pain which I can not bear sometimes, the only time I feel less pain is when I sleep.
Although I went to different doctors and had a plenty of tests, unfortunately I'm in the same situation. What would you advise me to do? because I am 24 years old and I can't do sports because of the pain thank you.
I used to have bulging disc of l5s1 for more than 2 years it was started when I was 17 , and I underwent an operation on my back one year ago but I still have problem in sitting I mean that I can't sit for more 20 or 30 minutes if I do it will be painful for me.
We r pain patient iam doing walking & jogging good are bad sacroiliac joints pain please give me answer
Dr lafahaa L5 l4 s1 is in pain what kind of treatment what do i do Dr i need i am in Dr
Dr. Nabil please can u help me, i am from india i am suffering pain from hip to toe of left leg i had went to neuro doctors but no solution
Hey very sorry to hear.I am too suffering from similar problem. HOWS YOUR CONDITION NOW.PLEASE REPLY.AND PLEASE TELL HOW CAN I HELP IT TO CURE.
No likho
हिंदी m bhi btaya laro