SI Joint Related Pain in a 60 yo Male

This was an interesting case that I thought worth mentioning.

In men, the SI joint rarely is the cause of LBP in my experience. In women of course, with a wider pelvis, and the hormone Relaxin softening the ligaments during the first and third trimester, we often see SIJ related pain especially post partum.

I recently saw a 60 year old male patient who had a three month history of pain that was so severe he was unable to tie his shoes or put on his socks. The pain was primarily in his right butt cheek and also in his upper thigh. His physician had ruled out his lumbar spine as the source of his pain. He eventually came to see me when he concluded that he was not getting any better with the passage of time.

His pain occurred when he bent over with his legs wide apart to lift a heavy object. The pain remained essentially unchanged during the past three months in spite of meds and rest.

My suspicion of the SIJ was confirmed by physical exam, and confirmed again when I reduced the subluxed joint.

So the lesson is this:

• Sudden onset unilateral pain in the butt that doesn't seem to get better with time suggests Sacro Iliac Joint pain
• Pain that comes on with an incident, traumatic, lifting or otherwise suggests SIJ pain.
• Pain that meds and rest does not resolve that interferes with weight bearing or hip flexion suggests SIJ pain

Not all back pain is back pain. Not all buttock pain is SIJ pain.

The combination of the history (which raises suspicions) and the physical exam which (confirms or refutes them) is the way to make the diagnosis. BUT, if you have unilateral pain in one butt cheek, AND there is an incident that preceded the pain, THEN you might have SIJ pain even if you are not a post partum female.

The dysfunction is easier to treat in men than women, but it can be treated in women successfully along with a stabilizing belt following the reduction of the subluxation that I wrote about earlier.

Post Meniscus Recovery - one week out

Well, two weeks ago I inured my knee, tearing my meniscus while working out at the track. A week ago I had a minor surgery to repair the torn medial meniscus. All that was needed was a trim of the tor material. With that I should be able to get back to my usual level of activity fairly quickly. I was prompted to have the surgery rather than wait because my knee was unable to straighten and weight bearing was very painful.

The surgery went great, in and out, and at first, while the nerve block was still active, I had very little pain. I went home and put my leg up, my knee on ice. I pretty much had a good day and went to bed thinking all was well.

Then the nerve block wore off! Oh My God..that was painful!!! So with pain meds on board I spent the next 12 hours sleeping.

But I continued to keep off my leg for the next 3 days and treated my knee with ice and electrical stimulation until I went back to work on Tuesday. Even though I iced and stimmed twice during the day, by the end of the day I was tired and sore. By Wednesday though the pain in my quads was quite severe, and my knee was not very happy. This time I used UltraSound on the scars and The Stick on my muscles, and I made it to Friday.

By Friday, one week out, I was no longer limping, but my ROM still had not returned (swelling) and I still have to remind myself to take NSAID's and take it easy.

Today, I will walk a bit, try a bit of rowing, and generally take it easy with my knee on ice.

The most interesting thing that I learned about this post surgical time is that by day 5, the muscles around the knee are really, really tight and sore and really do well with the Ultrasound.

On Thursday, I found myself at the foot of three flights of stairs in a building that has no elevator. That was the most work my knee had done since surgery and I painlessly managed by climbing slowly, although I was muscularly fatigued my knee swelled up a bit after that. I can see how easy it is to over do things. The leg feels like it can do more and I have to consciously restrain myself from moving too quickly, or stepping up or down with my surgical leg.

I am just happy that I was able to get my knee surgically repaired so quickly after I injured it. I am also lucky that the meniscus trimming is a relatively minor procedure because there is very little bleeding, if any, during the procedure, so the recovery is abbreviated.

My torn Medial Meniscus

So I was in training for life, and engaging in a drill where I did various plyometric drills down the track and sprinted back up the track at about 80%.

I did this after a long warm up - a 3 mile jog to the track.

On my 6th repetition, during the plyometric portion of the drill, I was skipping using big arms and gaining a lot of air each skip. After about 30 meters I felt my left knee complain a bit... not too much, but complain nevertheless.

I walked it off and sprinted back making a mental note that I was tired and still had a 3 mile jog ahead of me, so I put it all out there during my last sprint.

25 meters in, my knee went "crunch" and I pulled up with a gimpy left knee. I could not easily bear weight and at first I could not tell what I had done. It felt like my medial meniscus was damaged.

After a few minutes of standing there rubbing my knee, the pain along the medial joint line set in and I limped off home.

On Sunday I had an MRI confirming my suspicions, and tomorrow I go see the surgeon! Ouch. More to follow.

Can I run with Hardware On board?

I got a great question from Vitor about his hardware, the message is:

"Hello,

I had ankle surgery about a year ago following a motorcycle accident, and got a metal plate and some screws (don't know how many exactly). I used to run before the accident and surgery, but I only ran twice recently and stopped because I was afraid I might be doing something that might damage the bone because of screws and plate being there, although I didn't actually feel any pain while running. I've just imagined the screws damaging the bones with the running impact and stopped running. In a month I will have surgery to remove these metal plate and screws. Do you think I should wait until after the plate removal surgery to run?

Thank you very much!"

I responded:

Vitor, this is a really great question. When you have open reduction internal fixation (ORIF) the metal plates and screws serve as "stress risers" in the bone, which means that the bone is having to attenuate more force around the screws than they otherwise would have to if the screws were not there. Ultimately, these stress risers lead to local fractures. Additionally, the plates prevent the bones from flexing, bending and twisting. These are natural actions of the skeleton during the gait cycle especially during running activities which increases the impact loading over walking quite dramatically. The consequence of this is that other stress risers will also develop as the bone responds to the new stresses in new locations, and the result, you guessed it, fractures.

So the long and short of it is this, get the hardware removed, and then allow at least 6 if not 12 weeks to pass before you run again in order the bone to fill the screw holes. ORIF is unfriendly to runners!

Hope this helps,

Neil