Tell me how to diagnose my SI joint pain

Does this sound familiar?

It’s hard to sit. Maybe if I adjust how I’m sitting the pain will go away, or at the very least transfer to a new part of me that has had a break from the pain for a while. Tag, you’re it. Maybe standing will help.

But then.

The transition from sitting to standing hurts. 

Standing too long hurts, so you return to sitting.
Sitting too long hurts so you lay down

You want to roll over, but that hurts too.  

You adjust to ease the hurting, 

adjust again, 

Back to standing, standing too long, sitting too long, laying too long

on and on and on and none of it really ever helps.

You complain that it hurts, it burns, it stabs HERE, you point.
It feels off, unstable, wobbly… maybe you even feel like something is stuck back there like I did – like someone jammed a screwdriver not so politely into the joint.

You don’t know what to call it, the back, the butt, the hip, it’s all those places and none of those places.  But this pain that has come is interrupting your life and it’s not going away as you hoped.

So off to the internet you go. You find information on the SIJ and are convinced that is what’s hurting you. You want the doctor to confirm it so you can fix it and get rid of this horrible pain that is stealing movement and time from you. 

The pain does not go away, so you go to your doctor, hoping for a diagnosis.

Let’s get down to facts on how this all goes down ok.
Sacroiliac Joint Dysfunction is not an ICD-10 code. It is a common term used to describe pain in the SI area, but it is NOT a medical diagnosis. This is really important to understand as so many get frustrated when doctors say it isn’t real. SIJ pain is considered as a possible pain source AFTER other things have been ruled out.

Well, from a code standpoint it isn’t! Docs use all kinds of different codes to say SIJ pain, but SIJD is NOT one of them. Try not to get too upset if Doc doesn’t agree with the label you have given your pain. It doesn’t mean they don’t believe you, it just means you are speaking different languages.

According to back pain guidelines, no imaging should be taken, because only 1% of back pain is really from nasty stuff!  And YES SIJ pain is PART of low back pain. Important info to have so you and your doc are on the same page about stuff!

If you don’t’ have radiating leg pain, notable weakness, or lack of reflex response, again, imaging is not advised. (By the way, these things are common with SI pain, but not actually symptoms of SI pain!)

You “should” be sent to physical therapy… which then has its own diagnostic issues, but we will talk about those later in the post. 

At some point, you usually end up asking the doc for imaging because you are convinced the level of pain must mean something is terribly wrong inside. 

Your doctor orders x-rays, or maybe an MRI.

The purpose of these scans is not to rule IN your SIJ it’s to rule OUT other red flags and nasties. Your lumbar spine and your hips need to be cleared from pathologies to warrant looking at the SIJ. If pathology is found in the hips or spine – the investigation STOPS here. Treatment for these pathologies is what should be started next.

As we learned in the anatomy post, there are a lot of shared nerve pathways. So this is an important step! 

Let’s say your scans came back like most and there isn’t anything really exciting on them, this is actually good news. You don’t have anything really awful!
There may be minor tears or some Disc degeneration, we will talk about those findings in a future post, but for now, know that isn’t too uncommon. Especially if you are over 30.

While the literature seems to follow a very orthopedic flow for this pain we described, I do strongly advocate for a visit to a pelvic floor physical therapist to get things checked out. So many find relief from the pain with pelvic floor training. We forget those muscles are the inside of the pelvis, work like other muscles, and are often wildly overlooked as a driver in the pain we experience. It is rare for an MD suggests an exam by these skilled professionals.

The other element I often see missed or kicked down the road is when bilateral sacroiliitis is noted on scans. I strongly advocate that you find a rheumatologist and have them check things out. A fair number of autoimmune issues start at the SI joint, low spine. I would hate for someone to keep trying to “put your pelvis back in alignment” when your issue is really that your body is attacking itself and a few medications can wildly improve your life. Consider it for me, will you?

Ok, now you’ve done all that, and still, no one can “find the offending tissue that needs fixing”

*takes a deep breath*

What is supposed to happen next, is a provider should perform 6 provocation tests.
The point of these tests is to provoke your familiar pain. Fun huh?  Medicine has now proven it hurts where you have been telling them it hurts. Understanding the power of these tests is not to diagnose WHY it hurts, just where. If half of them (3/6) are positive the next step in the process is to move on to diagnostic injections.

Here is a lovely table of those tests, in case you are curious like me – and they are all over youtube! ( WARNING PT WORDS!)

DESCRIPTION OF PROVOCATION TESTS

Frankly, I think the Fortin Finger point test is more humane, and it’s almost as effective as the provocation tests in agreeing you have pain where you said you had pain. Again, can not tell you why you hurt, just that it does. 

See, it hurts here doc!

In your quest to prove your SI joint is what hurts, the next step is diagnostic injections into the SI joint. These injections sure are a buzz within Facebook groups and full of misunderstandings. Let’s clear that up ok.

First, best practice, or the gold standard for determining the SIJ as a reason for pain starts with all I have listed above. As a refresher: clear spine and hips with no pathology, 3/6 provocation tests are positive, followed by a series of three injections that reduce 75% or more of your familiar pain.

The injection must be guided by visualization, in research studies, they found docs missed far more often than hit it when going in without visualization. It is common practice for Docs to give them numbing agent ( which is what the diagnostic portion is!) and a steroid for treatment since they are there already.

You do not have to have the steroid. The diagnostic part is how you feel in the immediate time after the numbing agent is given. Not 8 hours later, not 3 weeks later – immediately! And if they are really good, they should PERFORM the provocation tests to see if your pain is lowered or eliminated with the numbing agent.  And this should be done 3 times because the rate of false positives is so high.

As we discussed in the anatomy post, the joint capsule is often torn, which means the numbing agent doesn’t stay in the joint, it oozes out into the nearby structures and nerves and that can lower your pain without it being from the joint. 

Is it the gold standard, yes, it is the best we have? Is it terribly reliable, no it’s not and doctors are aware of this. I will also remind you that these injections have confirmed you have pain where you said you did. They do not give a WHY to your pain, only a sort of WHERE.

The good news with all of this is 99% of low back pain is non-specific. That doesn’t mean there isn’t injured tissue, it just means we don’t have testing accurate enough to pinpoint what tissue it is.

The other really really good news is we now know nothing emergent is happening in you. We know your tissues are sensitive and that’s why you are in pain, but not so damaged they can’t heal or something is really nasty and wrong.

We know where it hurts, you told me in the first paragraph. Nothing scary came back on your scans and you had your pelvic floor checked out. That means we can safely recognize tissues are sensitive and begin rehab as the body heals any minor issues that are present. 

What that means is YOU CAN HEAL.



More reading!

LINK – How Do You Diagnose SI Joint Pain? Joseph D. Fortin, DO

LINK – Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests

LINK – Sacroiliac Joint Pain, an Updated Narrative

LINK– Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area