Differential Diagnosis of SI Joint Pain

Sacroiliac Joint pain can often be inappropriately treated or mistaken as lower back pain. There are several conditions that simulate sacroiliac joint pain.

1. Myofascial Painmyofacial pain

This is a chronic pain caused by multiple trigger points and fascial constrictions. This particular condition involves the muscles and fascial areas of the back. The patient may feel knots or hardening of the muscle with weakness and tenderness. Myofascial pain syndrome and fibromyalgia may present the same clinical picture but, they are different problems. The site location is close to the SI joint and can be confused with SI joint pain.

2. Trochanteric Bursitis

Inflammation of the greater trochanter bursa. This condition causes tenderness and pain bursapiriin the hip. Trochanteric bursitis occurs in middle aged women. The area of pain may overlap with the SI joint area of pain and can radiate close to the sacroiliac joint. The pain from this condition is sometimes severe and associated with iliotibial band syndrome. Trochanteric Bursitis is occasionally overlooked. This condition may present with arthritis of the hip and low back pain and other conditions.

 

3. Piriformis Syndrome

This condition occurs when the sciatic nerve is compressed by the piriformis muscle in the buttocks. Piriformis Syndrome may be associated with lower lumbar radiculopathy similar to spine pathology. It occasionally develops due to blunt trauma to the buttocks. Localized buttocks pain will increase with sitting or driving. Tenderness is commonly found in the sciatic notch.

piriformis

4. Cluneal Nerve Entrapment

cluneal nerve entrapThe superior cluneal nerve has three branches. The medial branch of this nerve is confined within a tunnel which may cause impingement of the nerve producing pain close to the SI joint.

5. Lumbosacral Disc Herniation or Bulge

The disc may move out of place (herniate) or break open (rupture) from injury or strain. Disc herniation of the lumbosacral region could involve the nerve roots, creating lower back pain. The pain is usually found in the midline and can go down the leg.

discherniation

6. Lumbosacral Facet Syndrome

facetThe facet provides stability for the spine and contain a joint. This joint may be affected by inflammations or degeneration which causes pain that can be mistaken for SI joint pain.

 

7. Lumbar Radiculopathy

Lumbar Radiculopathy is a major source of back pain. This condition occurs from inflammation, irritation, or impingement of the nerve root. It is commonly confused for SI joint pain.lumbarradi

 

 

 

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Pudendal Nerve Palsy

Damage to the pudendal nerve can occur suddenly as a result of trauma to the pelvic region, prolonged bicycling, fractures, or from falls. The pudendal nerve re-enters the pelvis under the sacrotuberous ligament and gives three branches.

usepudendalThe first branch, the inferior rectal nerve, provides rectal tone and perianal sensation. The second branch, the Perineal Nerve, gives scrotal sensation. The third branch, the dorsal nerve of the penis, give branches to the corpus callosum.

The pudendal nerve arises from S2, S3, and S4. The pudendal nerve carries sensations to the external genitals, the lower rectum, and the perineum.

The symptoms of pudendal nerve palsy can start suddenly or develop over time. Symptoms include the loss of sensation or numbness, burning or stabbing pain, difficulty with bladder and bowel functions, and sexual dysfunction.

morenerves

Causes of pudendal nerve palsy include prolonged sitting exercises such as bicycling or following fracture table traction—the nerve is compressed between the ischium and the hard object.

Treatment options are typically conservative, as the condition is usually transient and will improve over time. Treatment includes:

  • Restbike
  • Physical therapy
  • Stretches and exercises
  • Anti-inflammatory medications
  • Injections/nerve blocks
  • Surgery (as a last resort)

 

Prevention options for bicyclists consists of changing the sitting position while riding the bicycle and changing the seat from a narrow seat to a wider seat.

Galeazzi Fracture

Galeazzi Fractures are a type of fracture of the radial shaft which is associated with dislocation of the distal radio-ulnar joint (DRUJ). This particular fracture is name after Ricardo Galeazzi who was an Italian surgeon in Milan. This injury is uncommon and only accounts for about 7% of all forearm fractures in adults.

 

A radius fracture may be short, oblique, or transverse and involves a fractures at the junction of the middle third and distal third of the radius with associated injury to the distal-ulnar joint. The closer the fracture is to the DRUJ, the more likely that it will be unstable. Dislocation of the DRUJ is usually dorsal. It may be associated with either a ligamentous injury or fracture of the styloid process of the ulna.

styloid fx

A fracture is usually located above the proximal border of the pronator quadratus muscle. The distal fragment usually moves towards the ulna. Galeazzi fractures are best treated with open reduction and internal fixation of the radius and assessment of the distal radio-ulnar joint.

unstable

Surgery is necessary. Nonsurgical treatment in adults usually results in recurrent dislocations of the distal ulna and a bad outcome. Surgery is done by a volar plate fixation. Followed by assessment of the Distal Radio Ulnar Joint (DRUJ), if stable, the forearm will be splinted in supination for six weeks. If the joint is unstable, reduce and pin the distal radio-ulnar joint in supination for about four weeks. If the joint is not reducible, open and explore the joint. Check for entrapment of the ECU.

reduction

 

 

Avascular Necrosis of the Shoulder

Avascular necrosis is death of a segment of bone. AVN may affect the proximal humerus due to interruption of the blood supply. The ascending branch of the anterior humeral circumflex artery runs in the lateral bicipital groove and then becomes the arcuate artery. The other artery that is important to the blood supply is the posterior humeral circumflex artery.

avascccc

There are several risk factors for AVN including: Alcohol, Systemic Lupus Erythematosus, infection, trauma, and steroid use. 5-25% of AVN cases are due to steroid usage. Steroids increase the serum lipids in the blood which may precipitate fat embolism into the humeral head blood vessels.

posttrauma

proximal humeral pain

Progressive collapse of the humeral head occurs due to bone death, reabsorption, remodeling, micro fractures and final collapse with joint changes and arthritis. Symptoms include: shoulder pain, weakness, crepitus, and a decreased range of motion. Symptoms are gradual and insidious with delay in the diagnosis and treatment. The patient usually has a history of risk factors.

osteomri

In regards to imagining, x-rays will show the best in the neutral rotation AP view. AVN located on the superior middle part of the humeral head just deep to the articular cartilage. If the crescent sign is seen, this is an indicator of collapse. An MRI is going to be the best imaging study. A patient with AVN of the humerus should have a hip radiograph. If the x-ray is negative and the patient has hip pain, you should obtain an MRI of the hip. It is recommended that a patient with osteonecrosis at the site of the shoulder should undergo an MRI of the hip to rule out asymptomatic osteonecrosis of the hip. You may also need to do an x-ray of the knee. AVN may involve three or more anatomic sites (multifocal osteonecrosis).

Treatment typically consists of:

  • Physical Therapy
  • NSAIDS
  • Core decompression for Stage I and Stage II
  • Resurfacing for Stage III
  • Hemiarthroplasty for Stage III and Stage IV
  • Total shoulder surgery for Stage V
    • Advanced disease
    • The results of total shoulder are inferior to patients with osteoarthritis