I remember being thrilled in 1993 when I finally had a name for my pain. That kinda makes me laugh now because as we have been talking about, that name really doesn’t mean anything more than pain. Let’s note a few things about the definition. This really is a huge chunk of the problem when it comes to treatment. I mean seriously, how can we treat something accurately if we don’t agree on what it is other than pain.
1. SIJD is not a code any medical professional can use to bill, which means it is NOT an official diagnosis.
2. SIJD does not have a common definition amongst providers.
3. Some providers are still in the dark ages and say the sij can’t produce pain. sigh…… I can’t even on that one.
4. As we have discussed in this blog series, there are lots of reasons your SIJ area might hurt, and that doesn’t mean the “yellow brick road of treatments is going to work to make you pain-free or that you have to have surgery because none of them worked!
5. Chronic Pain is multifaceted. These treatments are only targeting one portion of even the biological possibilities and missing about a million other potential factors. Please try to keep that in mind. Have a read here for more on the complexity of chronic pain.
However, there is a very specific flow chart most of us go down in an effort to treat our tissues with this maddening crazy-making, just cut my leg off I don’t need it any more pain.
Without further fanfare, let’s go down SIJ Treatment option rabbit hole.
Stop 1 – Your Primary Care Doc.
You may get a variety of medications and usually an invite to go to Physical Therapy. I talk about this pathway here.
Stop 2 – Physical Therapy, Massage, Chiropractor, Doctor of Osteopathy:
For the most part, these schools of thought are looking for issues with your posture, alignment, or muscle weakness, or imbalances to explain your pain. Research has studied these issues as pain generators and the reality is these explanations are just poor. Super crazy poor and do not hold water when tested scientifically. I break down these pain myths here.
We tend to forget the nervous system is really what we need to be “treating” or focusing our attention on to change our pain. I considered blogging about how much placebo plays a part in treatments from all these providers and honestly got so angry that I had to stop researching. For now, let’s just say yes – seeing these people can and often do help your pain. However, it is usually not for the reasons you have been led to believe.
If pain alerts us to danger then feeling safe or comforted will absolutely help lower our pain for a time. Many of the manipulations and treatment options offered by these specialties DO help calm the nervous system AND are enhanced if you like the wall color, feel safe in the office, and enjoy the company of your provider. Frankly, trusting your provider and believing you can get better and 2 of the most important keys to actually getting better!
Do I recommend these types of interventions and practitioners? Yes. you must buy into your treatment and you must be getting better. Not just getting relief, but actually progressing towards YOUR goals of a larger life. If these treatments are only making you feel more fragile or merely keeping you in a holding pattern, it’s time for something different.
Within the medical system, you will be pushed into the following stops… treatments become more aggressive, more invasive, and more expensive. That does not make them more effective! If no one has suggested pain coaching, self-management, or peer support, you might consider these before hitting the next stops of medical intervention for pain.
Invasive treatments for SIJ pain
Stop 3- Pain Management for Injections:
Ah… the referral to pain management and the poking begins! The general approach here is that no one has “yet” been able to find your pain generator, so Doc will keep injecting places with numbing agents followed by steroids to find the offending tissue. A few things to consider here for any and all steroid injections:
- Steroids are not so great for connective tissue.
- Steroids work on inflammation… there is a GUESS that you have inflammation and that is why you have pain.
- When it comes to injections for the SIJ its far more specific than most think:
- Injections should come AFTER 3/6 positive provocation tests
- A series of 3 injections given under imaging is needed to confirm a positive dx
- the numbing agent is the test and you need to have a 75% reduction in your normal pain
- Someone really should repeat the provocation tests after the numbing agent has been administered.
- Don’t forget that the joint capsule is torn in many individuals up to 61% … which means the numbing agent spills out muddying the waters!
Injections should really only occur a few times a year because of the side effects. So if your Doc is saying yeah… but I can only give you 3 a year, they are keeping your best interest at heart. I will also add if a steroid is helping, I think it’s fair to ask, well what does that mean? WHY is the inflammation there? Do I have an autoimmune issue I should look into?
If injections are deemed to “not be working” whatever that means… then RFA is usually the next stop.
Stop 4 – RFA: radiofrequency ablation: also called Radiofrequency neurotomy
So what is RFA you ask? Great and often asked question. Electrical current is most often used to deaden a bundle of nerves. This is a procedure that can be done to multiple nerves and tissues. It is important that you understand what and where your doctor tends to perform this intervention.
There are also a variety of ways to create the lesion on the nerves, conventional, pulsed, or water-cooled radiofrequency.
In SI joint pain, these are the most common places for RFA ( Taken directly from spine health.com)
- Medial branch nerves transmit pain from the facet joint(s). Each facet joint is connected to 2 medial branch nerves that carry pain signals away from the spine to the brain.
- Lateral branch nerves transmit pain signals from the sacroiliac joint(s) between the sacrum and ilium in the pelvis to the brain.
“Use of RFA to treat facet-mediated chronic low back pain is controversial, with some studies showing “large-magnitude, durable improvements in pain and functional limitation, but other studies demonstrating limited benefit of this treatment,” the study researchers explained.” Huh? Yeah… this is saying we don’t have really good evidence that these are helpful. Why does that matter to you? Well… you have a diagnosis that is unclear, you have followed a treatment path that is unclear, and you are at your last medical stop before surgery is suggested because they “can’t stop your pain.”
“Currently, there is limited data from high-quality randomized controlled trials (RCTs) to demonstrate the efficacy of lumbar RFA,” explained senior author Janna L. Friedly, MD. “While there is some promising data from uncontrolled studies (primarily observational studies), RCTs are the gold standard for determining treatment efficacy. Despite this lack of RCT evidence, use of RFA and associated costs are steadily increasing over time as our study shows.”
(Quotes from an article at spine universe.)
Smaller studies done specifically for the SIJ were so poorly designed that I ended up not including them within this post. The bottom line is, it may help, it may not so please know much like everything else concerning SI joint pain far more studies need to be conducted before anything is “proven” as effective.
So if you are an “RFA dropout” or it didn’t work to cure your pain and you get shuffled on to surgery as your only option left. Please read on for the next blog post. Because it’s OTHER options you have that are rarely mentioned!
Stop 5- Surgery:
You’ve done it all. Every single thing you have been asked. Every TA exercise, every clamshell, every pill, every doctor appointment… you showed up. you did as you were told. You were the perfect patient. Yet, the pain never lets up. never goes away. never gets better for more than a moment. Your next medical stop is surgery.
There are about a million types of implants on the market now. So you have a wide variety of choices. Please know though that you are asking for “specialists” in the SIJ or this surgery… these are not medical specialties. They can have an interest and take classes and learn, just like me, but there is no track within medicine to make them specialists. It is a self-proclaimed title. Sometimes a laughable one. There are a handful of surgeons out there that have been doing SI fusions since way before it was popular. Those folks are the experts. They are the ones saying there is still so much we don’t know.
You’re angry because your insurance told you that it’s still experimental, well it is. Those random control trials we mentioned briefly in the RFA section… yeah, we need those for surgery too.
Do I think surgery is bad, no. I do think it’s done far too often with far too much conjecture. If you, as the one with pain are ok with that, then YES have the surgery. If you understand that we have lots of holes starting with diagnosis and they just continue to increase as we “fail” treatments that lead us to surgery… there are some huge pauses we should take. Lord knows our insurance and at least half of orthopedics and neurosurgeons are taking that pause.
Know your risks and then make your choice. Don’t settle. Be informed.
I know you want out of pain more than anything in this world. I want that for you too.
so I’ve been a wet blanket on the choices we have for getting out of pain offered by modern medicine. what do I think…. well, I invite you to my free Facebook group.
More reading on injections:
Mayo Clinic
Boston University Study on Cortisone injections: Injections treatment could speed up a joint’s disintegration and force patients to have total knee or hip replacements.
Paper from 1974 letting us know steroid injections can harm connective tissues
Validity and specificity of SIJ provocation tests
More reading on RFA:
Rates of Lumbar Radiofrequency Ablation on The Rise Despite Controversial Efficacy Data
Radiofrequency Ablation (RFA): Procedure and Recovery
