Meredith Grace: A 32-Year-Old Female With Right Ill-Defined Low Back and Buttock Pain





Learning Objectives





  • Learn the common causes of sacroiliac pain.



  • Develop an understanding of the unique anatomy of the sacroiliac joint.



  • Develop an understanding of the causes of sacroiliac joint arthritis.



  • Learn the clinical presentation of sacroiliac joint pain.



  • Learn how to use physical examination to identify pathology of the sacroiliac joint.



  • Develop an understanding of the treatment options for sacroiliac joint pain.



  • Learn the appropriate testing options to help diagnose sacroiliac joint pain.



  • Learn to identify red flags in patients who present with sacroiliac pain.



  • Develop an understanding of the role of interventional pain management in the treatment of sacroiliac pain.



Meredith Grace







Meredith Grace is a 32-year-old secretary with the chief complaint of, “I’ve had low back and butt pain since I slipped and fell at the airport.” Meredith went on to say that she wouldn’t have bothered coming in, but the pain was interfering with her Pilates class. I asked Meredith if anything like this has happened before. She shook her head and said, “Absolutely not. I’m in great shape, but I won’t be if you don’t get me better. This pain is really wearing me out, and the heating pad and pain pills just aren’t doing the job. Doc, I wouldn’t complain, but I have to exercise. I usually get up at 5:30 each morning for my Pilates, but I can barely get moving in the morning because my sleep is all jacked up because it hurts every time I roll over on my right side. Can you just give me a quick shot of something to get me back on track? I really need to get back to my routine.”


I asked Meredith about any antecedent trauma to the right sacroiliac joint prior to her slip and fall and she said no, that she wouldn’t have fallen if she hadn’t been in a hurry, and then there were the damn high heel boots and the wet floor. “After all,” she said, “my balance is great from all the yoga I do.” I asked Meredith to point with one finger to show me where it hurt the most. She pointed to the area of the right sacroiliac joint but noted that it was not well localized. I asked her if the pain radiated anywhere else and she said that sometimes it goes down into the area just below her right buttock, but it didn’t go below the knee. Meredith denied any other gynecologic symptoms, blood in her urine, or bowel or bladder symptomatology. Her last menstrual period was about 10 days ago. She was on oral contraceptives.


On physical examination, Meredith was afebrile. Her respirations were 18 and her pulse was 74 and regular. Her blood pressure (BP) was normal at 122/74. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. I did a rectal exam and pelvic, which were both normal. Visual inspection of the area over the right sacroiliac joint revealed resolving ecchymosis. The area overlying the right sacroiliac joint was cool to touch. Palpation of the right sacroiliac joint revealed moderate diffuse tenderness, with no obvious effusion. I performed a Stork test, which was positive, as were the Yeoman and Van Durson tests ( Figs. 14.1 and 14.2 ). The left sacroiliac joint examination was normal, as was examination of her other major joints. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of peripheral, entrapment neuropathy, or radiculopathy. The deep tendon reflexes were all normal and there were no pathologic reflexes.




Fig. 14.1


The Stork test for sacroiliac joint pain and dysfunction. (A) The Stork test: The patient is placed in the standing position with the examiner seated behind the patient. The examiner places one thumb on the patient’s posterior superior iliac spine and the other thumb on the base of the sacrum. (B) The Stork test: The patient is then asked to flex the hip and knee on the nonpainful side to at least 90 degrees while standing on the contralateral leg. (C) The Stork test: If there is no sacroiliac dysfunction, as the patient flexes the hip and knee, the thumb on the patient’s posterior superior iliac spine of the flexed leg will drop as the ilium rotates in a dorsocaudal direction to brace the pelvis to aid the other leg in receiving the full weight of the upper body.

From Waldman SD. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . 3rd ed. St Louis: Elsevier; 2016: Figs. 166-1–166-3.



Fig. 14.2


The Yeoman test for sacroiliac joint pain and dysfunction. (A) The Yeoman test: With the patient in prone position, the affected leg is flexed back toward the buttock to 90 degrees. (B) The Yeoman test: The examiner then displaces the ipsilateral ilium with firm downward pressure. (C) The Yeoman test: The examiner then extends the ipsilateral hip.

From Waldman SD. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . 3rd ed. St Louis: Elsevier; 2016: Figs. 166-1–166-3.


Key Clinical Points—What’s Important and What’s Not


The History





  • A history of acute trauma to the right sacroiliac joint after a slip and fall



  • No history of previous significant sacroiliac pain



  • Pain in the area of the right sacroiliac joint radiating into the base of the right buttock



  • Pain is not well localized



  • Pain does not radiate below the knee



  • Increased pain with standing, walking, and taking large steps



  • No fever or chills



  • No bowel or bladder symptomatology



  • Sleep disturbance



The Physical Examination





  • The patient is afebrile



  • Resolving ecchymosis over the right sacroiliac joint



  • Palpation of right sacroiliac joint reveals moderate diffuse tenderness



  • No point tenderness



  • No increased temperature of the painful areas



  • Positive Yeoman and Van Durson tests (see Figs. 14.1 and 14.2 )



  • Normal rectal and pelvic examinations



Other Findings of Note





  • Normal BP



  • Normal HEENT examination



  • Normal cardiovascular examination



  • Normal pulmonary examination



  • Normal abdominal examination



  • No peripheral edema



  • No groin mass or inguinal hernia



  • No CVA tenderness



  • Normal upper and extremity neurologic examination, motor and sensory examination



  • Examination of joints other than the right sacroiliac joint were normal



What Tests Would You Like to Order?


The following tests were ordered:




  • Plain radiographs of the right sacroiliac joint



Test Results


The plain radiographs of the right sacroiliac joint revealed no evidence of arthritis, fracture, or other abnormality ( Fig. 14.3 ).


Aug 9, 2021 | Posted by in PAIN MEDICINE | Comments Off on Meredith Grace: A 32-Year-Old Female With Right Ill-Defined Low Back and Buttock Pain
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