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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Common Foot Conditions and Injections

 

Conditions which cause pain and inflammation are treatable with the use of diagnostic and therapeutic injections. The purpose of this article is to shed some light on common ankle and foot conditions that may require injections and where the proper sites to perform these injections are located.

anklejoint

Ankle Joint

The ankle joint is formed by articulation of the tibia and talus. Injections are performed here to alleviate pain occurring from trauma, arthritis, gout, or other ankleeeeinflammatory conditions. Anterolateral Ankle Impingement can occur due to the build-up of scar tissue in the ankle joint or from the presence of bony spurs. When executing an injection here, the ankle will need to be in a neutral position. The physician will mark the injection site just above the talus and medial to the tibialis anterior tendon. The injection site should be disinfected with betadine. Then, the needle is inserted into the identified site and directed posterolaterally. The solution is injected into the joint space and should flow smoothly without resistance. It may be helpful to pull on the foot in order to distract the ankle joint.

First Metatarsophalangeal Joint

The MTP joint is a common injection site frequently affected by gout and firstmetaosteoarthritis. The injection site is first disinfected with betadine and then the needle is inserted on the dorsomedial or dorsolateral surface. The needle is angled at 60-70° of the plane to match the slope of the joint. The solution is injected into the joint space and should flow smoothly without resistance. Pulling on the big toe is sometimes helpful in distracting the joint.

 

Peroneal Tendonitis

Peroneal Tendonitis is an irritation to the tendons that run on the outside area of the ankle, the peroneus longus and peroneus brevis. First, the injection site is disinfected with betadine. Then, the needle should be carefully inserted in a proximal direction when injecting the peroneus brevis and longus tendon sheath. The needle will need to advance distally to inject the peroneus brevis alone at its bony insertion.

peroneal

Achilles Tendonitis

Achilles Tendonitis is an irritation and inflammation of the large tendon in the back of the ankle. Achilles tendonitis is a common overuse injury that occurs in athletes. needlingInjections of steroids should be given around the tendon, not through the tendon. The injections inserted directly into the tendon is not recommended due to the increased risk of tendon rupture. A platelet injection can be done through the tendon with needling and fenestration.

 

Tarsal Tunnel Syndrome

Tarsal Tunnel Syndrome is a condition of pain and paresthesia caused by irritation to the posterior tibial nerve. When performing an injection for this condition, the tarsal tunnelphysician will want to feel the pulse of the posterior tibial artery. The nerve is posterior and the physician will want to find the area of maximum tenderness. The injection site should be 1-2cm above the tender area, which is marked on the medial side of the foot and disinfected with betadine. The solution is injected at a 30° angle and directed distally. It is important to inform the patient that the foot may become numb and that care should be taken when walking and driving. Injections for Tarsal Tunnel Syndrome are usually performed after a treatment program which can include rest stretching and the use of shoe inserts.

 

Plantar Fasciitis

The plantar fascia is a band of connective tissue deep to the fat pad on the plantar aspect of the foot. Patients with plantar fasciitis complain of chronic pain symptoms that are often worse in the morning with walking. The injection site is identified and marked on the medial side of the foot and betadine is used as a disinfectant. The physician will need to avoid injecting through the fat pad at the bottom of the foot to avoid fat atrophy. The needle is inserted in a medial to lateral direction one finger breath above the sole of the foot, in a line that corresponds to the posterior aspect of the tibia. The solution is injected past the midline of the width of the foot.plantar

 

Radiation Exposure and Safety

X-rays ionize human tissue and deposit energy that can cause harmful changes within the body (break the DNA chain). Additionally, there is a cancer risk from exposure to x-rays. The dose of radiation is cumulative. X-rays are considered carcinogenic. The government is attempting to minimize the use of unnecessary CT scans and x-rays to prevent unnecessary exposure to radiation. It is important for doctors to pay close attention to the risks involved with the use of x-rays. The cancer risk associated with radiation exposure is documented in cases of atomic bomb survivors.

radiationThe risk for medical uses is controversial and usually played down by physicians. Radiation at a high level is carcinogenic but, the level of radiation from x-ray exposure is low. The effects of low level radiation is not known.

What is the safe radiation level?

The safe level of radiation is not known.

ctscanIt is known that CT scans, fluoroscopy, mammography, and x-rays expose the public to high levels of radiation, especially in young females. The risk of exposure should balance the medical benefits.

Optimize radiation doses by only exposing the patient to enough radiation to get a clear image. There is a growing concern about the risk associated with giving a patient large doses of radiation. The use of CT scans has increased recently in adults and children, possibly exposing the patient to an unnecessarily high dose of radiation. A CT scan is often the method used to diagnose cancer, diseases, and fractures, exposing the patient to a much larger dose of radiation than x-rays. Radiation from a CT scan of the pelvis equals the same amount as 100 chest x-rays. Children are ten times more sensitive to radiation than adults. 3-4 million children receive CT scans and about 1,500 of them will develop cancer two decades later. Additionally, children should not be given an adult dose of radiation.

Radiation Dose Limits

dose limitsA CT scan of the pelvis has the highest level of exposure to the skin, marrow, and gonads. A mini fluoroscopy C-arm should be used whenever possible. Fluoroscopy emits a lot of radiation. The closer the extremity is to the radiation source, the higher the dose of radiation the patient receives. When the distance from the beam increases, the dose of radiation is less. Attempt to decrease exposure time. Radiation intensity follows the inverse square law. It is all about distance!

If the intensity of radiation at 1 meter from the source is 100mR/hr, then the intensity of radiation at 2 meters from the source is ¼ or 25mR/hr in the same unit area. At 3 meters from the source, the intensity of radiation is 1/9 the original or 11.1mR/hr.

inversion square lawUnits of Radiation

  • Roentgen
    • Unit of radiation exposure in the air
  • Rad
    • Energy absorbed per gram of tissue
  • Rem
    • Biological effect of a rad

There is less exposure to the physician when imaging a smaller body part. Larger body parts create an increased exposure to the physician when imaging a patient with the C-arm. It is important to not be in the direct path of the radiation beam.

less expoMethods of protection include: monitoring, shielding, and position. A dosimeter badge records how much radiation you have received; however, it does NOT protect you from exposure to radiation. Lead gowns and aprons work to stop exposure to fluoroscopic radiation. Lead aprons attenuate scattered radiation by about 95%. Rapidly dividing cells are most sensitive to radiation exposure and include: sperm, lymphocytes, and cells inside the small intestine and stomach.

Radiation damage seldom appears at the time or irradiation. The first effects of radiation damage is usually seen as a drop in the white blood cell count. The first external sign of damage is usually a skin burn. Studies suggest that people who use fluoroscopy extensively have a higher rate of cataracts.

Early effects of radiation exposure include:

  • Death
  • Hematologic depression
  • Chromosome aberration
  • Skin erythema
  • Epilation

My recommendations:

A CT scan examination is usually done without justification by most insurances. In my opinion, 1/3 of CT scan studies that are given could be avoided; they are an added cancer risk with no benefit. The CT scan study should be justified. There is no close oversight or uniform standard in place to eliminate radiation exposure, and this is something that should be taken seriously.

shieldPatient education is important. The patient should ask if the study is necessary and what is the lowest dose possible that can be given without compromising the study. Additionally, there should be a universal x-ray bank where patient’s x-rays can be accessed by any medical facility. This would eliminate the unnecessary repeating of x-rays.

In summary, the bone marrow, breast tissue, gonads, and lymphatic tissue are susceptible to radiation induced tumors. It is important to shield the gonads from exposure. Always wear protective equipment such as lead aprons and monitor your radiation exposure with the dosimeter badge.

Tillaux Fractures

ankle anat

In adults, ligaments are weaker than bone. The anterior tibiofibular ligament in adults is torn first in the majority of ankle fractures. In children, the growth plate is weaker and can become avulsed. An avulsion injury is rarely seen in adults because the ligament gives out instead of avulsing the bone.

growth plaateTillaux fractures occur in adolescents, usually around 12-15 years of age. These fractures occur after the middle and medial parts of the epiphyseal plate closes and before the lateral part is closed. The lateral part of the growth plate remains open, which could allow for an avulsion fracture at the attachment of the anterior tibiofibular ligament. An external rotating force causes an avulsion of the distal tibial epiphyseal plate anterolaterally. Further lateral rotation displaces the fracture and may be associated with fracture of the lateral malleolus. external rotation

Treatment

If the fracture is displaced 2mm or more, the surgeon will want to perform a reduction and fixation. This fixation can be done from either lateral to medial or medial to lateral. Wagstaffe’s fracture is an avulsion of the anterior portion of the fibula by the anterior tibiofibular ligament. This type of fixationinjury is associated with supination external rotation type injuries (Lauge-Hangen) and typically occurs in adult patients.