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A case report of sacroiliac joint dysfunction with urinary symptoms
Manual Therapy (1998) 3(4), 220-221 © 1998 Harcourt Brace & Co. Ltd
Case report
A case report of sacroiliac joint dysfunction with urinary symptoms T. R. Dangaria
Department of Orthopaedic Surgery, Jerudong Park Medical Centre, Brunei Darusaalam
SUMMA R E Patients with sacroiliac joint (SIJ) dysfunction have various presenting symptoms. An unusual case of SIJ dysfunction presenting primarily with urinary urgency is described. The symptoms were relieved completely after the successful manipulation of the SIJ.
INTRODUCTION
The patient had a past history of an episode of low back pain 10 years earlier. This had lasted for about 1 month. Since then, she had not experienced any trouble from the back until this present episode. Subjectively the patient did not appear to have any underlying emotional stress.
The sacroiliac joint (SIJ) and the specific diagnosis of SIJ dysfunction is often overlooked as a cause in the symptomology of the low back pain and pain of the lower extremities. The SIJ is anatomically an atypical synovial joint and it has extensive innervation. This may account for multiple modes of pain presentations (Daum 1995). So far in the literature, urinary symptoms in association with SIJ dysfunction have not been described. The patient presented in this case study had low back pain and urinary urgency with frequency that did not have any apparent aetiology from the urinary tract. SIJ manipulation was performed for the low back pain. This relieved the low back pain and also the urinary symptoms immediately. The identical spinal segment of nerve supply for the SIJ and urinary bladder might be one of the explanations for this outcome.
Clinical examination There was no tenderness on palpation of the spinous processes of the lumbosacral spine. The paravertebral muscles in the lumbosacral area demonstrated moderate spasm. When performing the straight leg raise (SLR) test on the right side, the patient developed pain in her low back that radiated down her fight thigh to the knee on the lateral side at 70 degrees of hip flexion. Bragard's test was also positive on the fight side (where dorsiflexion of the ankle, at the point of elicitation of the backache and leg pain during SLR, aggravates the backache and leg pain). Sensation was diminished in the L4 and L5 dermatome on the fight side, while muscle power and reflexes were normal in both lower limbs. Spinal lateral flexion movements of the spine were normal and the finger to floor distance was 15 cm. Extension of the spine was equal to full range and pain free. Tenderness on palpation was present over the area just medial to the right posterior inferior iliac spine (PIIS). This tenderness was decreased by pushing the sacrum upwards (cranialization). There were no painful indurations along the iliac attachments of the gluteal muscles. The length of the right lower limb was 2 cm longer on flexed sitting posture. In the standing and sitting forward flexion tests, the right PIIS moved first in the cranial direction. The ipsilateral kinetic test in standing for innominate flexion/lateral rotation (spine test) yielded no inferomedial displacement of
CASE REVIEW Clinical presentation A 27-year-old Caucasian female patient presented with complaints of low back pain, frequency and urgency of micturition for 10 days. The low back pain and urinary symptoms had had a simultaneous onset. Sitting, turning over in bed, climbing stairs, sneezing and coughing aggravated her low back pain whilst standing and lying down gave her relief. She had occasional radiation of the pain to the right lower limb, on the lateral side, up to the knee without paraesthesia. There was no history of any trauma or strain of the back. Dr Trikam Dangaria, MD (Orthopaedics), Department of Orthopaedics, Jerudong Park Medical Centre, 2021, Jerudong Park, Brunei (via - Singapore). 220
A case report of SIJ dysfunction
the HIS on the right side. All these clinical facts were useful in establishing the clinical diagnosis of a right SIJ dysfunction. No tenderness was found over the kidney-bladder area.
Other investigations Urine cytology examination was normal. Roentgenological examination of the lumbosacral area including magnetic resonance imaging (MRI) failed to reveal any pathological findings.
Treatment The history and clinical examination suggested that the patient was suffering from right SIJ dysfunction with associated urinary symptoms that required investigation and management by the urologist. An MRI of the lumbosacral spine was arranged to exclude underlying lumbar disc pathology for pain and urinary symptoms. Meanwhile, the patient was treated with Diclofenac, a non-steroidal anti-inflammatory drug (NSAID) and a back strengthening exercise programme for 1 week. This regime did not give rise to relief of her low back pain and her urinm'y symptoms remained unchanged after a week. As the MRI showed normal findings, it was planned to initially treat the SIJ dysfunction by manipulation, followed by a consultation with the urologist for her urinary symptoms. Sacral mobilization (cranialization) was carried out in the sidelying position by a thrust technique. Thereafter, manipulation with a muscle energy technique having the left leg crossed over the right knee in a supine position was performed. After the manipulation, no analgesics were prescribed.
Results The NSAIDs and back strengthening exercises that were prescribed failed to relieve symptoms after 1 week. Following manipulation and sacral mobilization, signs of the right SIJ dysfunction disappeared and the patient had immediate relief of the low back pain as well as the urinary symptoms. On re-examination, mild tenderness was elicitable on the spinous processes of L5 and S 1. No relapse of urinary symptoms have occurred in the 10 months since the SIJ manipulation.
DISCUSSION Urinary symptoms occurring due to SIJ dysfunction is unknown. However, these two conditions could occur
© 1998 Harcourt Brace & Co. Ltd
221
concurrently. In this case, manipulative treatment for SIJ dysfunction relieved the urinary symptoms unexpectedly. Numerous tests and treatments are proposed for the examination and treatment of the SIJ dysfunction. Depending upon the experience of the clinician, SIJ dysfunction may be over or under diagnosed. Nowadays, manual therapy is preferred to conventional therapy for patients diagnosed as having SIJ dysfunction. The school of medicine that the physician has attended also plays an important role in the choice of diagnostic tests and treatment methods in manipulative therapy. Innervation of the SIJ is provided by fine nerve branches derived exclusively from dorsal rami of spinal nerves S1-$4, which is not always consistent. This innervation pattern may provide explanations for various patterns of pseudoradicular and referred pain in SIJ affections, for example dysfunction, arthritis etc. (Grob et al. 1995). Post ganglionic fibres of the hypogastric plexus having $2-$4 segment of origin innervate the detrusor and the internal sphincter of the urinary bladder. The external sphincter has a nerve supply from the pudendal nerve that arises from the ventral components of the sacral nerves ($2-$4). Thus, the voluntary and involuntary nerve supply for emptying of the bladder has the identical segment at nerve supply to the SIJ. This anatomical background may hint to the possible mechanism for irritation of the bladder in SIJ dysfunction (Chusid 1976). Joint manipulation is widely utilized to decrease pain and increase the range of motion of joints displaying limited mobility. Evidence of efficacy is widely based on subjective reports of symptom improvement as well as on the results of clinical trials. These findings indicate that joint manipulation exerts physiological effects on the central nervous system, probably at segmental level. The fact that the changes persisted in the presence of cutaneous anaesthesia suggests that reflex changes are likely to be mediated by joint and/or muscle afferents (Murphy et al. 1995). Relief of urinary symptoms after successful manipulation of SIJ dysfunction in this case suggests a possible neurological link is responsible for this effect.
References Chusid J G 1976 The autonomic nervous system. In: Correlative Neuroanatomy and Functional Neurology, 16th Ed. Lange Medical Publication, California, pp 139 Daum W J 1995 The sacroiliac joint: an under appreciated pain generator. American Journal of Orthopaedics 24(6): 475-478 Grob K R, Neuhuber W L, Kissling R O 1995 Innervation of the sacroiliac joints of the human. Zeitscrift der Rheumatologie 54(2): 117-122 Murphy B A, Dawson N J, Slack J R 1995 Sacroiliac joint manipulation decreases the H-reflex. Electromyography. Clinical Neurophysiology 35(2): 87-94
Manual Therapy (1998) 3(4), 220-221
Case report
A case report of sacroiliac joint dysfunction with urinary symptoms T. R. Dangaria
Department of Orthopaedic Surgery, Jerudong Park Medical Centre, Brunei Darusaalam
SUMMA R E Patients with sacroiliac joint (SIJ) dysfunction have various presenting symptoms. An unusual case of SIJ dysfunction presenting primarily with urinary urgency is described. The symptoms were relieved completely after the successful manipulation of the SIJ.
INTRODUCTION
The patient had a past history of an episode of low back pain 10 years earlier. This had lasted for about 1 month. Since then, she had not experienced any trouble from the back until this present episode. Subjectively the patient did not appear to have any underlying emotional stress.
The sacroiliac joint (SIJ) and the specific diagnosis of SIJ dysfunction is often overlooked as a cause in the symptomology of the low back pain and pain of the lower extremities. The SIJ is anatomically an atypical synovial joint and it has extensive innervation. This may account for multiple modes of pain presentations (Daum 1995). So far in the literature, urinary symptoms in association with SIJ dysfunction have not been described. The patient presented in this case study had low back pain and urinary urgency with frequency that did not have any apparent aetiology from the urinary tract. SIJ manipulation was performed for the low back pain. This relieved the low back pain and also the urinary symptoms immediately. The identical spinal segment of nerve supply for the SIJ and urinary bladder might be one of the explanations for this outcome.
Clinical examination There was no tenderness on palpation of the spinous processes of the lumbosacral spine. The paravertebral muscles in the lumbosacral area demonstrated moderate spasm. When performing the straight leg raise (SLR) test on the right side, the patient developed pain in her low back that radiated down her fight thigh to the knee on the lateral side at 70 degrees of hip flexion. Bragard's test was also positive on the fight side (where dorsiflexion of the ankle, at the point of elicitation of the backache and leg pain during SLR, aggravates the backache and leg pain). Sensation was diminished in the L4 and L5 dermatome on the fight side, while muscle power and reflexes were normal in both lower limbs. Spinal lateral flexion movements of the spine were normal and the finger to floor distance was 15 cm. Extension of the spine was equal to full range and pain free. Tenderness on palpation was present over the area just medial to the right posterior inferior iliac spine (PIIS). This tenderness was decreased by pushing the sacrum upwards (cranialization). There were no painful indurations along the iliac attachments of the gluteal muscles. The length of the right lower limb was 2 cm longer on flexed sitting posture. In the standing and sitting forward flexion tests, the right PIIS moved first in the cranial direction. The ipsilateral kinetic test in standing for innominate flexion/lateral rotation (spine test) yielded no inferomedial displacement of
CASE REVIEW Clinical presentation A 27-year-old Caucasian female patient presented with complaints of low back pain, frequency and urgency of micturition for 10 days. The low back pain and urinary symptoms had had a simultaneous onset. Sitting, turning over in bed, climbing stairs, sneezing and coughing aggravated her low back pain whilst standing and lying down gave her relief. She had occasional radiation of the pain to the right lower limb, on the lateral side, up to the knee without paraesthesia. There was no history of any trauma or strain of the back. Dr Trikam Dangaria, MD (Orthopaedics), Department of Orthopaedics, Jerudong Park Medical Centre, 2021, Jerudong Park, Brunei (via - Singapore). 220
A case report of SIJ dysfunction
the HIS on the right side. All these clinical facts were useful in establishing the clinical diagnosis of a right SIJ dysfunction. No tenderness was found over the kidney-bladder area.
Other investigations Urine cytology examination was normal. Roentgenological examination of the lumbosacral area including magnetic resonance imaging (MRI) failed to reveal any pathological findings.
Treatment The history and clinical examination suggested that the patient was suffering from right SIJ dysfunction with associated urinary symptoms that required investigation and management by the urologist. An MRI of the lumbosacral spine was arranged to exclude underlying lumbar disc pathology for pain and urinary symptoms. Meanwhile, the patient was treated with Diclofenac, a non-steroidal anti-inflammatory drug (NSAID) and a back strengthening exercise programme for 1 week. This regime did not give rise to relief of her low back pain and her urinm'y symptoms remained unchanged after a week. As the MRI showed normal findings, it was planned to initially treat the SIJ dysfunction by manipulation, followed by a consultation with the urologist for her urinary symptoms. Sacral mobilization (cranialization) was carried out in the sidelying position by a thrust technique. Thereafter, manipulation with a muscle energy technique having the left leg crossed over the right knee in a supine position was performed. After the manipulation, no analgesics were prescribed.
Results The NSAIDs and back strengthening exercises that were prescribed failed to relieve symptoms after 1 week. Following manipulation and sacral mobilization, signs of the right SIJ dysfunction disappeared and the patient had immediate relief of the low back pain as well as the urinary symptoms. On re-examination, mild tenderness was elicitable on the spinous processes of L5 and S 1. No relapse of urinary symptoms have occurred in the 10 months since the SIJ manipulation.
DISCUSSION Urinary symptoms occurring due to SIJ dysfunction is unknown. However, these two conditions could occur
© 1998 Harcourt Brace & Co. Ltd
221
concurrently. In this case, manipulative treatment for SIJ dysfunction relieved the urinary symptoms unexpectedly. Numerous tests and treatments are proposed for the examination and treatment of the SIJ dysfunction. Depending upon the experience of the clinician, SIJ dysfunction may be over or under diagnosed. Nowadays, manual therapy is preferred to conventional therapy for patients diagnosed as having SIJ dysfunction. The school of medicine that the physician has attended also plays an important role in the choice of diagnostic tests and treatment methods in manipulative therapy. Innervation of the SIJ is provided by fine nerve branches derived exclusively from dorsal rami of spinal nerves S1-$4, which is not always consistent. This innervation pattern may provide explanations for various patterns of pseudoradicular and referred pain in SIJ affections, for example dysfunction, arthritis etc. (Grob et al. 1995). Post ganglionic fibres of the hypogastric plexus having $2-$4 segment of origin innervate the detrusor and the internal sphincter of the urinary bladder. The external sphincter has a nerve supply from the pudendal nerve that arises from the ventral components of the sacral nerves ($2-$4). Thus, the voluntary and involuntary nerve supply for emptying of the bladder has the identical segment at nerve supply to the SIJ. This anatomical background may hint to the possible mechanism for irritation of the bladder in SIJ dysfunction (Chusid 1976). Joint manipulation is widely utilized to decrease pain and increase the range of motion of joints displaying limited mobility. Evidence of efficacy is widely based on subjective reports of symptom improvement as well as on the results of clinical trials. These findings indicate that joint manipulation exerts physiological effects on the central nervous system, probably at segmental level. The fact that the changes persisted in the presence of cutaneous anaesthesia suggests that reflex changes are likely to be mediated by joint and/or muscle afferents (Murphy et al. 1995). Relief of urinary symptoms after successful manipulation of SIJ dysfunction in this case suggests a possible neurological link is responsible for this effect.
References Chusid J G 1976 The autonomic nervous system. In: Correlative Neuroanatomy and Functional Neurology, 16th Ed. Lange Medical Publication, California, pp 139 Daum W J 1995 The sacroiliac joint: an under appreciated pain generator. American Journal of Orthopaedics 24(6): 475-478 Grob K R, Neuhuber W L, Kissling R O 1995 Innervation of the sacroiliac joints of the human. Zeitscrift der Rheumatologie 54(2): 117-122 Murphy B A, Dawson N J, Slack J R 1995 Sacroiliac joint manipulation decreases the H-reflex. Electromyography. Clinical Neurophysiology 35(2): 87-94
Manual Therapy (1998) 3(4), 220-221