Sacroiliac Joint Dysfunction

Patient presents with complaints of low back pain, specifically localized to the sacroiliac joint region.  The onset of pain is described as insidious, gradually worsening over the past [duration].  The patient reports pain as [character of pain: e.g., sharp, dull, aching, burning] and rates its severity as [pain scale rating] out of 10.  Pain is exacerbated by activities such as [aggravating factors: e.g., prolonged standing, sitting, bending, twisting, climbing stairs, walking] and is relieved by [relieving factors: e.g., rest, ice, heat, over-the-counter pain medication].  Physical examination reveals tenderness to palpation over the sacroiliac joint, positive findings on provocative maneuvers such as the FABER test, Gaenslen's test, and compression distraction tests.  Range of motion in the lumbar spine is [description of range of motion: e.g., within normal limits, reduced with pain on flexion, extension, lateral bending].  Neurological examination is unremarkable, with no sensory deficits or motor weakness noted.  Differential diagnosis includes lumbar disc herniation, facet joint syndrome, piriformis syndrome, and other causes of pelvic girdle pain.  Based on the patient's history, physical examination findings, and clinical presentation, a diagnosis of sacroiliac joint dysfunction is made.  Treatment plan includes conservative management with physical therapy focusing on core strengthening and stabilization exercises, manual therapy, and modalities such as heat and ice.  Patient education on proper body mechanics and activity modification is provided.  Referral to a pain specialist or orthopedic surgeon will be considered if symptoms do not improve with conservative treatment.  Follow-up appointment scheduled in [duration] to assess treatment response.  ICD-10 code: M54.31.