Case Study: SIJ Dysfunction Masquerading as Lower Back Pain in Active Older Male

Our Patien

Our patient is a 65 year-old male complaining of chronic low back pain located above the pelvic rim. He complained of stiffness, with difficulty walking and bending, although he reported no pain with sitting. 

The Challenge

The patient brought with him an MRI that indicated multilevel severe disc disease with spinal stenosis. He had seen multiple doctors and physical therapists, had years of physical therapy, tried acupuncture, and had multiple epidural steroid injections, none of which resolved his chronic low back pain. He had consulted with three different surgeons, all of whom wanted to operate on his spine. 

Our Diagnostic Process

Clinical Exam

During the clinical exam it became clear that none of the patient’s symptoms matched disc or stenosis pain. There was tenderness on palpation of the regions of the spine where he complained of pain, prompting us to take a closer look.

Ultrasonography Exam

Using high resolution ultrasound imaging, we found:

• Severe multifidus atrophy
• Spinal enthesiopathy at his exact pain points
• Loss of lumbodorsal fascial tension
• SI ligament enthesopathy
• Sacrotuberous ligament thickening and enthesopathy
• SI joint dysfunction reproducing his secondary symptoms 

From our findings we determined that his pain was not discogenic – it was caused by soft tissues and mechanical overload.

Ultrasound Images of SIJ Ligaments

Our Initial Treatment Approach

We initially used ultrasound guided focal shockwave therapy, along with extracorporeal mechanotransduction therapy (EMTT) targeting the enthesopathic sacroiliac joint and its iliocostal attachment. In just 3 weekly sessions, the patient’s mobility improved by 80%. 

After weeks 4 and 5, the pain was completely gone, and he was now able to walk for an hour at a time. However, surprising new symptoms emerged just above his sit bones and behind his hips. 

We conducted another ultrasound exam that showed: 

• Lower pole sacroiliac ligamentopathy where the gluteus medius muscle attaches to the SI joint.
• Tendinopathy of the retrotrochanteric conjoint tendons, and enthesopathy of the sacrotuberous ligaments.
• Bilateral changes in echogenicity of the lateral hip tendons.
• Small partial thickness tears in the posterior head of gluteus medius.

These findings indicated a failure of tensegrity in the SI joint, which made sense, since  the multifidi spinal muscles were atrophied and tension had been lost in the lumbodorsal fascia, increasing stress on the sacroiliac ligaments and disrupting the posterior chain. This all pointed to the real problem: pelvic ligament and posterior-lateral hip tendon/capsule failure.

Our Secondary Treatment Approach

Once we identified the problem, we delivered one treatment of Prolotherapy followed by PRP injections into the pelvic ligaments, hip tendons, joint capsule, and multifidi. We also trained the patient in SI joint force closure, multifidi activation, intra-abdominal pressure activation of the core, and lateral hip strengthening.

Final Outcomes

Our treatment approach fully restored stability and tensegrity, and completely eliminated the patient’s low back, hip and pelvic pain – all without surgery.  The patient was able to return to his home in the Catskills of Upstate New York, where he walks for miles every day without pain. 

The Takeaway

Misdiagnosis of lower back pain is not uncommon. In this case, surgery would not have eliminated the problem and the patient’s health would likely have suffered for it. Most chronic low back pain is not generated from the discs shown on MRI. It comes from loss of fascial tension, ligament dysfunction, inefficient pelvic mechanics, and spinal soft-tissue failure — factors that cannot be visualized with MRI.

Ultrasound imaging finds the true causes of low back pain, guides treatment procedures, and ultimately changes patient outcomes for the better.