Inflammation SI joint
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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The sacroiliac joint is a joint that lies at the junction of the spine and the pelvis.
Sacroiliac joint inflammation can be a difficult problem to diagnose for a few reasons:
• The SI joint is not easy to palpate
• Several other problems (back pain, sciatica, hip arthritis, etc.) can cause similar symptoms
Palpation tenderness may be the first clue. Certain tests can place stress across the joint, and may indicate a problem. One test, called the FABER test, is done by lying down, flexing the hip, abducting the leg, and externally rotating the hip. This maneuver places pressure directly across the sacroiliac joint.
Magnetic resonance imaging can help establish the presence of inflammation.
Sacroiliac joint inflammation not due to systemic arthritis may respond to conservative therapy. The first step in treatment is to avoid the activities that cause symptoms. For athletes, this may mean avoiding their sport to let the inflammation subside.
Second, an anti-inflammatory medication can help to minimize the inflammation. It is important to understand that the anti-inflammatory medication is not given as a pain medicine, but rather to decrease the inflammation.
Physical therapy can help strengthen the muscles around the SI joint and low back and help increase flexibility around the joint.
If all these treatments fail, an injection of cortisone into the joint may be effective. Because the SI joint is deeper within the body than most joints, the cortisone injections should be given under ultrasound guidance.
Another relatively common cause of sacroiliac inflammation is ankylosing spondylitis.
This is an inflammatory form of arthritis involving the spine. It causes pain and stiffness in the back. The inflammation, left untreated, may eventually cause the vertebrae fuse together.
Inflammation of the tendons and ligaments that connect and provide support to joints can lead to pain and tenderness in the ribs, shoulder blades, hips, thighs, shins, heels and along the bony points of the spine.
The disease course is highly variable, and while some individuals have episodes of transient back pain only, others have more chronic severe back pain that leads to differing degrees of spinal stiffness over time. In almost all cases the disease is characterized by acute painful episodes and remissions (periods where the problem settles).
AS is a member of the family of diseases that attack the spine. These are named spondylarthropathies. In addition to AS, these diseases include Reiter’s syndrome, some cases of psoriatic arthritis and the arthritis of inflammatory bowel disease.
It usually appears in people between the ages of 15 and 40.
AS is three times more common in men than in women. It typically affects young people, beginning between the ages of 15 and 30. It may affect younger people also, although in very young people it may take a slightly different form, causing pain around the heels, knees, and hips rather than beginning with the spine. Onset after age 40 is uncommon.
Warning signs of ankylosing spondylitis:
• Frequent low back pain.
• Back stiffness that lasts longer than 30 minutes first thing in the morning or after a long period of rest.
• Pain and tenderness in the ribs, shoulder blades, hips, thighs, shins, heels and along the bony points of the spine.
• Mild fever, loss of appetite and general discomfort.
• Eye inflammation (iritis, uveitis)
The universal symptom of AS is chronic low back pain. The pain is typically worse in the morning. On rising from bed, people with AS may feel stiff and sore and this may take anywhere from 30 minutes to several hours to wear off.
The back pain is usually dull and diffuse. The most common site of pain is deep within the buttock, on one side, or on both sides. In addition to the buttock, there can be pain further up the back, perhaps between the shoulder blades or in the neck.
To avoid the pain there is a natural tendency to stoop forward. This reflex can lead to bad posture. Also in bed there is a tendency to curl up, as this may feel more comfortable.
Stiffness of more can lead to progressive disability.
While spinal stiffness is to be avoided, even greater potential disability can occur if AS affects the hips, knees or shoulders. The hip joints are often involved and can progress to where the joint is damaged, becoming limited in mobility, and painful.
Of the non-spinal joints, the hips are the most commonly involved and to a lesser extent the knees and shoulders.
The joints between the ribs and the spine and between the ribs and the breast bone (sternum) can also become painful and stiff. Stiffness of these joints can result in decreased chest expansion.
Although it is relatively uncommon, there is a possibility of inflammation involving the aorta.
AS tends to run in families. One of the genetic tissue types, HLA-B27, is found in only 6% of the general population but occurs in approximately 93% of individuals with AS.
The HLA-B27 tissue type, while not causing AS, does predispose individuals with the B27 tissue type to developing AS.
There is no cure for ankylosing spondylitis but there are things you can do to lessen your pain and maintain your movement and function.
Since AS often affects young, active males, it is sometimes misdiagnosed as mechanical low back strain.
The most common type of medicine used to treat ankylosing spondylitis is non-steroidal anti-inflammatory drugs (NSAIDs). These drugs help reduce the pain and swelling of the joints and decrease stiffness. However, they do not prevent further joint damage.
For those with severe disease who have inflamed joints, disease-modifying anti-rheumatic drugs, DMARDS, are used to slow progression of disease. Sulfasalazine and methotrexate are examples of DMARDs. DMARDS act slowly and take about two to six months before having the desired effect.
Biologic therapies are very effective for treating ankylosing spondylitis. Examples of biologics that appear to work well are etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade) and golimumab (Simponi).
For severe pain and inflammation, doctors can inject a corticosteroid directly into the affected joint using ultrasound guidance. However, this treatment can only be used rarely, since corticosteroids can weaken the cartilage.
Exercise is one of the most important activities in managing ankylosing spondylitis. Exercise helps keep joints moving and reduce pain.
Other activities such as swimming, walking and cross-country skiing also encourage good posture.
Gentle stretching exercises are important to prevent stiffness and postural changes.
Heat or cold application can provide temporary relief of pain.
Anesthesia also poses a risk if there is severe neck involvement. Cases of neck fracture with spinal cord compression have been reported.
Patients with severe AS involvement of the neck also should try to avoid sudden acceleration and deceleration in motor vehicles.
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