SI Joint Dysfunction - Member Case Study

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I'd noticed occasional pain in the back of my left leg once in a while when running. The pain is now running from my buttocks to the knee. I am having occasional back aches too.

Question from CindyK


I'd noticed occasional pain in the back of my left leg once in a while when running. I trained successfully for a 1/2 IM with little trouble. Then a couple of weeks after my race I noticed that running was becoming increasingly difficult. (This was in mid-late Sept.of last year). The pain that had originally been in the back of my thigh was now running from my buttocks to the back of my knee, and on longish runs (>8 miles) I was limping a little and it felt like my left foot was slapping the ground instead of rolling normally. My leg began hurting while swimming too. The pain would last all day sometimes. I also began having occasional backaches, down low and on the right side.

I went to my gp (in Nov) and he diagnosed SI joint dysfunction and wanted to begin cortisone injections. He hadn't done an MRI so I said 'no' and found a physical therapist. She believes that my right piriformis muscle is tight and/or spasming and very strong, pulling my SI joint out of alignment, which is consequently pulling on the left piriformis and compressing my sciatic nerve. My therapy consists of electrical stimulation, ultrasound, and massage combined with exercises intended to strengthen my left side. (However, they are exercises I was already doing with my pilates and yoga work). Right now there are no limits on my activity other than no running. My PT and I will revisit that subject on Friday, as I asked if a few weeks rest might help me recover more quickly. She is reluctant to restrict me but seems to think that a rest would be beneficial. Another PT in the clinic examined my old running shoes and says I have a supination problem. He will check my running stride this Wed.

I guess my questions are: Does all of this sound feasible? Should I be limiting my activities (roughly 2 hrs/day of combined low intensity base building, weights, yoga, and pilates)? Would a couple of weeks to focus on just the strengthening exercises help? Are there options I should be considering? I've been in PT for 3 weeks with little progress - the sciatic pain is slightly better and the back pain is worse. I'm registered for a 1/2 IM in July and would rather rest now than later if that's what I need.
 



Answer:

Your PT is addressing the mechanical aspects they have seen in your evaluation. This is not unreasonable and seems to be addressing most of the aspects I would consider in the history you present. I would also recommend more manual therapy -- to include things like myofascial release and functional movement patterns in the stretching and exercise components also. You did not mention if ‘downward-facing dog’ or other yoga postures increased or decreased your symptoms.

 

Also, if you are using the reformer in Pilates, note if any of the leg/pelvis work affects your symptoms. This would help in determining if some of the other potential causes for your pain are present (from a history viewpoint). I like yoga and Pilates for many reasons, but, the PT is important to the dynamic core/trunk stabilization and movement issues needed. Cross training with low-impact exercise for a short time may help minimize symptoms.

I am concerned about a problem with your lower back contributing to your symptoms. It seems that PT is achieving a more centralized component to your pain which is one approach to treating your symptoms. Without examining you, it is difficult to determine if you have a back problem in the lower lumbar disc that refers pain into your leg. Certainly, sacroiliac joint pain and muscles in the gluteal region may cause pain in this distribution, however, it is NOT common for it to cause weakness.

 

The most concerning mention in your history is your left foot ‘slapping the ground instead of rolling normally’. I have seen issues in the leg related to a tightening feeling and then relative weak feeling occur, but it is usually felt in the lower leg. With weakness, especially if onset is since you saw your physician, I would get re-evaluated for the possibility of a pinched nerve root related to your lower back. I have seen presentations of herniated lumbar discs that irritate the nerve root giving similar symptoms to your history. I have also seen tight muscles in the hip rotators (piriformis is example) also cause radiating pain, but not usually the ‘foot slap’ complaint you mention.

 

Your physician can evaluate if new weakness is present, if your reflexes are decreased and may consider an electrodiagnostic study (electrical study with small shocks on surface of skin, and, needle pricks –a fine wire that records electricity in your muscle) or imaging of your spine. I would be reevaluated now, if 1) you have had six PT visits without change, or, 2) the weakness is new since you saw the physician.

This is not meant to take the place of your physician’s advice and, because I am concerned about the back issue and your weakness as important issues, I have not answered your strengthening questions.

Katherine L. Dec, MD Member AMSSM

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date: April 9, 2005

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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