What is the management plan for a patient with pelvic pain and a CT scan showing ankylosis in the left sacroiliac joint, degenerative changes in bilateral hips, and stable proliferative changes at the femoral head/neck junction?

From the Guidelines

The management plan for a patient with pelvic pain and imaging findings of left sacroiliac joint ankylosis, bilateral hip degenerative changes, and stable femoral head/neck junction proliferative changes should prioritize a multifaceted approach focusing on pain control, physical therapy, and potentially local injections, as suggested by recent guidelines and studies 1.

Key Components of Management

• Pain control with NSAIDs such as naproxen 500mg twice daily or ibuprofen 600mg three times daily, along with acetaminophen 1000mg three times daily as needed.
• Physical therapy focusing on core strengthening, gentle hip mobility exercises, and posture correction, implemented twice weekly for 6-8 weeks.
• For moderate to severe pain, consider a short course of muscle relaxants like cyclobenzaprine 5-10mg at bedtime for 1-2 weeks.
• Local injections with corticosteroids may be beneficial for targeted relief, particularly for the sacroiliac joint or hip joints.

Considerations for Specific Conditions

• The presence of ankylosis in the left sacroiliac joint may suggest an inflammatory arthropathy, such as ankylosing spondylitis, which should be considered in the management plan 1.
• Degenerative changes in bilateral hips indicate osteoarthritis, contributing to the patient's symptoms, and should be addressed through weight management and potentially assistive devices like a cane or walker.
• The stable proliferative changes at the femoral head/neck junction may not require immediate intervention but should be monitored for any changes or progression.

Imaging and Diagnostic Considerations

• Diagnostic imaging, including CT scans and potentially MRI, should be used in conjunction with clinical signs and symptoms to guide diagnosis and treatment, as imaging alone has limited ability to confirm the diagnosis of a particular condition as the cause of pain 1.
• The use of anteroposterior pelvis and lateral femoral head–neck radiographs, as well as advanced imaging like MRI or CT scans when indicated, can provide valuable information for diagnosing hip conditions characterized by hip-related pain 1.

From the Research

Management Plan for Pelvic Pain with Sacroiliac Joint Ankylosis and Degenerative Changes

The patient's CT scan shows ankylosis in the left sacroiliac joint, degenerative changes in bilateral hips, and stable proliferative changes at the femoral head/neck junction. Based on the evidence, the management plan for this patient may include:

• Conservative treatment consisting of a multimodal program combining patient education, pelvic girdle stabilization with focused stretching, and manipulative therapy, as suggested by 2
• Nonsurgical modalities such as activity modification, use of a sacroiliac belt, NSAIDs, and physical therapy, as recommended by 3
• Diagnostic and therapeutic injections into the sacroiliac joint, which can be both diagnostic and therapeutic, as mentioned in 3
• Consideration of prolotherapy and radiofrequency ablation as potential therapeutic modalities, although limited data support their use as a primary treatment modality, as noted in 3
• Surgical treatment, including percutaneous SI arthrodesis, may be indicated for patients with a positive response to an SI injection with >75% relief, failure of nonsurgical treatment, and continued or recurrent SIJ pain, as suggested by 3

Considerations for Degenerative Changes

The patient's degenerative changes in bilateral hips and stable proliferative changes at the femoral head/neck junction should be taken into consideration when developing a management plan. As noted in 4, degenerative changes of the sacroiliac joint are highly prevalent in the asymptomatic population and are associated with age. Therefore, caution must be exercised when attributing lower back or pelvic girdle pain to sacroiliac joint degeneration seen on imaging.

Diagnostic Considerations

The diagnosis of sacroiliac joint dysfunction can be challenging, and a complete history and physical examination are critical in differentiating other diagnoses that may have similar signs and symptoms, as mentioned in 2. The use of imaging modalities such as SPECT-CT may be helpful in diagnosing sacroiliac joint incompetence, as suggested by 5.

Inflammatory Joint Disease Considerations

Although the patient's CT scan does not show evidence of inflammatory joint disease, it is essential to consider the possibility of conditions such as ankylosing spondylitis, rheumatoid arthritis, and gouty arthritis, which can cause degenerative changes and joint instability, as discussed in 6. A thorough medical history and physical examination are necessary to rule out these conditions.