Monday, April 1, 2013

Sacroiliac Pain - A Pain in the Butt or the Hip?

If you have pain in your buttocks, you’re not alone. You may have seen doctors who diagnosed you with degenerative disc disease or sacroiliac joint dysfunction. For years, I was chasing the sacroiliac joint dysfunction diagnosis – with massive amounts of physical therapy and even prolotherapy – but nothing ever helped.

I thank my lucky star that not a single doctor suggested the increasingly popular sacroiliac joint fusion procedure. It’s not that maybe some patients benefit from an SI fusion. What worries me are all the patients who get their SI joints fused when the SI joint itself is not the root cause of the problem. 
It took seven (!) years before I was diagnosed with hip impingement and labral tears in both hips. That is why my book The Entrepreneurial Patient: A Patient’s Guide to Hip Impingement deals with some of the diagnostic challenges and differential diagnoses associated with sacroiliac/hip pain.

According to a 2007 study by Dr. Philippon and others, 52% of hip impingement patients (301 hips) complained of deep buttock pain and 23% or sacroiliac pain (subjective descriptions) (1). The results of study from the Department of Orthopaedic Surgery at the University of Minnesota were recently published. In the study, the researchers hypothesized that patients with documented sacroiliac pain might provide insight into the (poorly documented) aetiology of these symptoms. The authors questioned whether SI joint symptoms might be associated with abnormal hip x-rays.

Let’s jump right to the conclusion: Overall, 76% had at least one abnormality on their hip x-ray. CAM impingement (extra bone on the ball or the junction between ball and neck) was visible in 33% of hips. A significant number of patients meeting strict diagnostic criteria for SI joint pain had radiographic evidence of femoroacetabular impingement (FAI) and hip arthrosis. The authors advised doctors to consider FAI in the differential diagnosis when investigating patients with buttock pain. (2)

Here are the details: The researchers reviewed the pelvic and hip x-rays of a cohort of 30 consecutive patients with SI joint pathology. This database included 33 hips from 30 patients. In this cohort 42% of hips had evidence of significant osteoarthrosis. In assessing acetabular (socket) anatomy, 21% had retroversion, 12% had a lateral centre edge angle >40° with 3% >45°. Tönnis angle was <0° in 27%. Coxa profunda and acetabuli protrusio were present in 47% and 3%, respectively. When femoral head (ball) morphology was assessed, 33% showed evidence of CAM impingement. (2)

As patients work through the diagnostic process of finding out what body part generates the buttock pain it might be useful to consider the following statements. A diagnostic hip injection that DOES NOT remove pain in the buttock(s) only means that the pain in the buttock is not directly referred from the hip joint. There could still be problems in the hip joint(s) that cause muscle imbalances and soft tissue pain causing pain in the buttocks (gluteal muscles etc.). A diagnostic injection in the SI joints will, on the other hand, remove buttock pain that is a direct result of pain in the actual sacroiliac joints. A word on steroids: They only help if there is inflammation and may even be irritating to some people to the amount of fluid going into a space. A diagnostic injection should always contain a numbing medication (anesthetic). (3)
Be an entrepreneurial patient and question a healthcare professional who is very quick to suggest a procedure such as an SI fusion. Read up on the topic and make sure you get the proper diagnostic workup.
(1)    Clinical presentation of femoroacetabular impingement. Philippon, Marc J., et al., et al. 2007, Knee Surgery Sports Traumatolog. Arthroscopy, Vol. 15, pp. 1041-1047.
(2)    Symptomatic sacroiliac joint disease and radiographic evidence of femoroacetabular impingement. Morgan PM, Anderson AW, Swiontkowski MF. Hip Int. 2013 Feb 12:0.
(3)    The Entrepreneurial Patient: A Patient’s Guide to Hip Impingement by Anna-Lena Thomas

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