Skip to content
Advertisements

Case Study: an interesting case masked as a simple “Sacroiliac joint syndrome”…orthopedic testing leads us astray once again !!

February 2, 2010

A very interesting case presented to me that I though would be of interest as it overviews many important examination concepts:

A 48-year old male distance runner presented to my clinic with a chronic history of lumbar pain in the region of L4-L5 (14 year history).  More recently the patient complains of pain also occurring in the area of the right PSIS and describes a ‘referral pattern’ going into the lateral pelvis (over the greater trochanter), and the antero-lateral thigh.  The patient has been to several manual therapists including RMT’s, PT’s, and DC’s, all of which focused on the sacroiliac joint as the primary cause of the patient’s pain.  Treatments have included deep tissue massage, spinal manipulation, SI joint stabilization, and a battery of modalities…all of which provide temporary relief to the progressing problem.

Physical examination of this patient provided ‘tricky’ results.  Range of motion testing produced pain in the PSIS region with right lateral bending and extension.  Orthopedic testing such as Kemps test, SI joint compression and Yeomen’s test all caused pain in the area of the PSIS (of course those who know me know that I did these tests last…after palpation, in order to discover why the condition went un-noticed for so long) Even more confusing was the fact that palpation in the area of the PSIS seemed to reproduce the patient’s pain leading to what seems like a logical diagnosis of SI joint problems.   However, as is always discussed in Functional Anatomic Palpation Systems (F.A.P.) © seminars, specificity is the key to success, especially when performing a palpatory examination….

Upon further palpatory assessment it was discovered that the pain in the region of the right SI joint was actually being produced by palpation of the most posterior insertion of the posterior fibers of the gluteus medius which insert just lateral to the PSIS.  Palpation of the dorsal sacral ligament failed to reproduce pain symptoms.  ASIDE — I have never seen or witnessed a true SI joint problem that did not have pain with palpation of the long dorsal sacral ligament.  Further examination of this muscle demonstrated palpable tension throughout the entire muscle.  A similar finding was discovered with palpation of the gluteus minimus, as well as the gluteus minimus and the tensor fascia lata…..

Another common topic that I discuss at my seminars is that of deciphering the process affecting soft tissues via the palpation of the tissue ‘quality.’  The finding of a “tight muscle” does not provide any information regarding the pathological process affecting the tissue.  Generally ‘tightness,’ or tissue tension can be caused by mechanical or neurological processes.  By ‘mechanical’ I am referring to physical changes in the tissues physical structure such as scarring or fibrosis.  In the case of ‘mechanical tension,’ the palpatory finding is rarely present throughout the entire muscle and is most often limited to a single segment of the encapsulating fascia at it’s insertion, MTJ, a portion of the belly, or between it and the adjacent epimysium of another muscle.  By a neurological process leading to muscle tightness I am referring to a frictional irritation of the innervating nerve (the so called “entrapment” – to learn more about the problems surrounding the term ‘nerve entrapment’ click here) that causes increased depolarization due to a decreased threshold that can lead to increased neural drive to a muscle…or ‘spasm.’  In these situations, specific palpation will reveal tension/contraction throughout the ENTIRE muscle.  Such was the case with this patient.

Getting back to our patient, the finding of neurologically induced tightness in three muscles all innervated by the same nerve, namely the superior gluteal nerve lead my examination “centrally.”  Palpation of the lumbar spine in the original region of the patient’s chronic pain symptoms revealed ‘neurological tension’ in the lumbar multifidus at L4/5 on the right.  Palpation of this structure also caused a reproduction of the patient’s pain in the buttock, and thigh (BTW – yes you can palpate the multifidii…yes you can distinguish between fibrosis vs. spasm in multifidii).

Following this finding I sent the patient for a plain film lumbar series, which revealed foraminal encroachment at L4/5 on the right as was suspected.

Theory: Nerve root irritation can lead to a decreased depolarization threshold thus resulting in an increased contraction of muscles ‘served’ by that segment.  In the case of our patient, increased depolarization central lead to increased depolarization at the superior gluteal nerve (which I find to be a common finding clinically), which lead to the increased and sustained contraction of the gluteus medius, gluteus minimus, and the TFL.  ‘Neurological tension’ was also palpated in the corresponding segmental multifidus…also a very common finding.  All of which lead to the suspicion of a neuropathic pain process occurring…hence the decision to send for plain films that surprisingly was never perused with this patient previously!

As I am sure you all know, the management of this patient will differ immensely now that a specific diagnosis has been discovered.

Advertisements
4 Comments leave one →
  1. February 3, 2010 2:16 am

    Great article some docs just don’t spend the time to establish a solid diagnosis. I am a chiropractor in Reno, Nevada and I hear similar stories from a lot of new patients to my office. The main difference is that I spend the time to determine if the patient is actually suffering from the most commonly presenting problem (in this case SI Joint Dysfunction) or something completely different. Glad to see there are more docs out there that still value an accurate diagnosis.

  2. August 27, 2011 1:47 am

    Dre,

    Were they booked in for surgery to debride this foraminal encroachment? My hands can not rub out bones. How many asymptomatics have foraminal encroachment?

    Second question, if surface EMG can’t target the lumbar multifidus how can our hands (Stokes et al 200?)? I think I can get close but I have never verified this. Just a thought for a post.

    Thanks for the case study, lovely review of anatomy and good critical thought.

    Greg

    • August 27, 2011 2:59 pm

      Hey Greg

      the patient did not have a ‘hard’ root entrapment….ie. the pain was not constant which leads me to believe that there was ‘room’ for the nerve root to move in the foramen. Of course, when we are dealing with encroachment type problems, the symptomatology is most often a result of neural irritation and inflammation, rather than direct compression (unless the encroachment is severe). Thus, there are patients with foraminal encroachment who are asymtomatic. Several of my patients for example with cervical encroachment have symptoms of radiculopathy which cease with a bout of therapy and rest (for the nerve)….they will remain asymptomatic for a period, then return with the symptoms again. I assume, as occurs in cases of joint degeneration, that the periods of no pain indicate that the inflammatory process has ceased. During periods when the symptoms return, this would represent an irritation of the arthritic joint resulting in an accumulation of inflammation…leading to the neural irritation.

      Treatment in these cases are obviously not focused on ‘rubbing out the bones,’ but on releasing any soft tissue fibrosis, and providing postural advice to allow time for the nerve to ‘heal’ and for the inflammation to reduce.

      Regarding the multifidii, as you note, it is very difficult to get deep enough to palpate, especially when a patient is simple prone or seated. In F.A.P., we teach a method which allows us (to the best of our abilities) slacken the overlying erectors (which are mostly composed of fascia at these levels) thus layering them, in order to palpate the underlying tissues. Of course, as with any deep palpation, we are not granted direct access to the multifidii, but by using compression of the overlying tissues in a slackened state, we can compress them to their ‘thinnest’ possible state against underlying tissues in order to palpate. It would be similar to the process of palpating the suboccipital group through the semispinalis capitis, or the piriformis through the gluteus maximus.

      thanks for the question….and I enjoy reading your blog btw. For my readers, I highly suggest you check out http://thebodymechanic.ca

  3. August 30, 2011 12:44 am

    Thanks Dre,

    Great response.

    Greg

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: