What I learned from seeing my third physiatrist

I had a pretty interesting experience yesterday that I thought I’d share with you all– the good and the bad.

I saw a physiatrist at Mass General Hospital who was actually familiar with treating the SIJ.  (A physiatrist is a type of doctor that treats physical dysfunction, similar to an orthopedist or a pain specialist.  People always think I’m saying “psychiatrist,” but I’m not).

I actually came across her while doing research for this blog, because I found the slides from a presentation on SI joint dysfunction she’d given to an athletic training conference.  I scheduled the appointment months ago, more out of a sense of intellectual curiosity than anything else, since I was doing so much better.

However, the truth is that I’ve had a few setbacks recently.  It started with my fall on the ice over the winter, and since then I haven’t been able to work out as much as I want because my allergies have made me so congested.  My SIJ’s have been moving around a little bit more recently than I’d like.  So, as luck would have it, there actually were a few things for Dr. M and me to talk about yesterday.

I did talk to Dr. M. and get her permission to give her (full) name in this post, because every so often people ask me for recommendations for doctors etc. in the Boston area.

However, upon reflection, I decided not to put her name in because I want to be honest about my experience– the good and the bad.  My disappointments are not with her personally so much as the overall experience.  Yet I thought they were important to include, because for me they shed light on the process of trying to find help for the SIJ as a patient.  (And you can always email me if you’re looking for recommendations).

So, let’s get started.  I guess I will start out by talking about what was good:

The Good

She actually knew what I was talking about when I mentioned SI joint dysfunction.  She’s really only the second doctor I’ve come across in five years who I can say this about.

She was very thorough and mentioned the need to rule out a rheumatological condition, such as ankylosing spondylitis.  She initially wanted to send me to a rheumatologist until I told her about the significant amounts of blood work my primary care physician had ordered over the years, which always came back normal.

She suggested that, since I’ve had this problem for so long, it might be a good idea to have some imaging done.  First, she wanted an x-ray of my low back and SI joints, and then if I still had trouble in the future, an MRI of my lower back.

Just to be clear– SIJ dysfunction doesn’t show up on imaging.  The x-rays would be to rule out any kind of inflammatory condition.  The MRI would be to check for degenerative changes within my spine that could be causing pain.  Sometimes pain from the lumbar spine can “refer” into the SI joint area.

I did think this was going to largely turn out to be unnecessary, since I’d managed to make my SIJ’s pain-free before, I feel fairly confident I know exactly what to do to make them that way again.  However, this was the first time she’d ever met me as a patient and wasn’t familiar with my story.  So I really respected her thoroughness– I can’t really think of a good reason why no one had suggested this before.

She was familiar with other treatments I’d heard of for the SI joint, but which no one had really offered to perform on me.

Basically, physiatrists specialize in improving function.  They don’t perform surgery; they don’t go in and change the structure of your body.  Their specialty is improving the function of what’s already there, so to speak.

So one of the things they specialize in is offering different therapeutic injections.  Some of the options Dr. M. offered to me include:

• Lidocaine injection in the muscles around the SI Joint (to numb things and reduce pain– also called a trigger point injection, when it is done to relax a muscle knot)
• Lidocaine injection in the ligaments of the SI joint (for the same purpose, to numb and reduce pain)
• Cortisone injection in the SI joint itself– in other words, injecting an anti-inflammatory steroid into the joint space itself, between the ilium and the sacrum.  Cortisone injections are a step up, in terms of seriousness, from lidocaine, because they do more than just numb– they shut down your inflammatory processes in that part of your body in a pretty heavy duty way.  This means the benefits can last for weeks.  There are pros and cons, and they don’t always help.

I’m not actually planning to have any of these done right now– I’m not really in pain and I don’t think I need them.  Right now I think I just need to give my ligaments a little more time to heal, and to get back to where I was, exercise-wise, before my allergies messed things up.  But I’m including them as options here, for anyone else who is looking for info in the SIJ.

The not so good

One of the things I found really disappointing about my visit, although this isn’t at all personal, is that Dr. M. did not really seem to know what I was talking about when I mentioned my SI joint getting stuck.

This has actually really been the biggest symptom for me with SIJ dysfunction, more so than pain.  It’s that one of my hip bones will rotate backwards, ever so slightly (like a millimeter or so) enough to get jammed against the sacrum, and then it’s hard for me to walk.

I know this from my chiropractor visits, and from finally finding two physical therapists over the years who knew what I was talking about, and knew how to correct it with the muscle energy technique.

So it was a little disappointing to feel as though this doctor didn’t really understand.  She didn’t contradict me or tell me I was wrong.  She just looked a little confused herself, and said that most of the SI joint problems she sees in women have to do with hypermobility on both sides that causes pain.  (Hypermobility means the joint is moving too much).  The joint getting locked up would be the opposite– hypomobility, or not moving enough.

I guess I’d been hoping, based on what I’d read online, that Dr. M. would be able to make me feel like I wasn’t so much of a special case.  It didn’t turn out that way, at least not completely.

I did explain that chiropractors had been the first ones to explain this concept to me, of the SI joint getting stuck.  I wasn’t sure what her thoughts would be on chiropractors, but she seemed to respect the idea and looked more thoughtful than skeptical.  I felt as though maybe I’d given her food for thought.  So that was something, at least.

The appointment was way too short

This, of course, was not Dr. M.’s fault.  In fact, she accidentally left her schedule for the day up on the computer screen when she left the room after our appointment.  Obviously I wasn’t going to look at other patients’ names or whatnot, but I did see that every appointment was exactly 15 minutes long, and the next patient after me was already waiting.  Clearly, she didn’t make her own schedule.  This was just what Mass General had decided, and it probably had a lot to do with how they get reimbursed by insurance companies.  So really, I blame the insurance companies.

But 15 minutes was just not enough, and I feel that short appointment times like this have been a major factor in why it’s taken me so long to find answers.  I need to write more about this in the future, but I feel short appointments have been a huge factor even with the people who really ended up helping me. There was never enough time– sometimes their great ideas, that ended up being huge turning points on my road to healing, came as afterthoughts, when I’d bombard them with questions, even as they were trying to make their way out the door to the next patient.

Someday, if and when I’m a PT, I vow that this will be less of a factor for me.  Now I know why so many of the best PT’s stop even taking insurance.  (Right now I’m thinking of opening a private practice where I offer a sliding scale– hopefully I’ll be able to live on that!).

What I learned

One of the most interesting parts of the whole appointment, for me, was of course, the questions I asked Dr. M. towards the end, as she was trying to wrap things up to go see her next patient.

What I asked her was why, in her opinion, it was so hard to find doctors who were knowledgeable about the SIJ.

Her answer, I think, largely depended on her training and the niche of medicine that she worked in, because I know from my research that there are surgeons who operate on the SI joint.

But generally, her answer is in keeping with the way the majority of doctors practice medicine.  So what she said was that surgeons, in general, aren’t interested in the SI joint, because there’s nothing they can really fix.  They want to change structure.

SI joint dysfunction, in general, is not a structural problem, it’s a functional problem.  The same joint can operate more or less optimally based on things like ligament integrity and muscle strength.  (And although this is not the case with me, it can cause a lot of pain when the joint is inflamed, which can be helped by an injection, not surgery).

So, Dr. M. said that she really thought the best people to see for an SI joint dysfunction were physiatrists, because they specialize in improving function, or else pain specialists (anesthesiologists).

It really sounds counter-intuitive to think you’d have better luck with an anesthesiologist than an orthopedist, but again, it seemed to have more to do with the philosophy of each specialty (a pain management specialist also being someone who focuses on improving function and treating pain, whereas an orthopedist focuses on operating and changing structure).

“The main treatment for SI joint dysfunction is to strengthen the core muscles.”

This was Dr. M.’s most immediate recommendation.  Of course, I already knew that gaining muscle strength was probably the most important thing, but it was interesting to hear her say it with such certainty, and also to focus so clearly on the core.

My approach, generally, has been to also try to strengthen the muscles of the low back and hips as well, which I’m sure no one would argue with.  But I also know from my reading that the muscles of the core– the transverse abdominis, specifically– play a major role in stabilizing the SI joint when they contract, almost like a brace.  So I definitely see why she said that, and I’m definitely going to factor that in in the future when people ask me advice.  (I’ve had quite a few requests recently for a post about my pool exercises, so that is coming ASAP!).

“When it comes to PT, it’s really important to find the right fit.”

This, believe me, is something I already knew.  I just also found it interesting for her to say it, because I’ve heard a lot of doctors talk about PT’s as though they are interchangeable, like car mechanics.  You ought to be able to go to just anyone.

But honestly, if there’s anything I’ve discovered in my years as a patient, it’s that when you have a complex, chronic condition, finding the right physical therapist is almost like dating.  For real.  You have to find someone who has the knowledge to help you, and also the right approach and level of compassion so that you can form a therapeutic relationship.  It can be really, really hard to find the right mix.

So that’s all for now.

I hope this post was helpful to you.  I know I wanted to record some of these thoughts for myself, because I feel Dr. M.’s words shed a lot of light both on some of the treatments for the SI joint, as well as kind of how the medical field works as a whole, and why it’s so hard to find help.

Any questions, feel free to comment below or email me!