Sacroiliac Joint Syndrome

Patient presents with complaints of low back pain, specifically localized to the sacroiliac joint region, possibly radiating to the buttock, groin, or thigh.  The onset of pain may be related to a specific incident such as a fall, lifting heavy objects, or prolonged standing, or it may have developed gradually.  Physical examination reveals tenderness upon palpation of the sacroiliac joint, positive findings on provocative maneuvers such as the FABER test, Gaenslen's test, or compression and distraction tests.  Pain may be described as sharp, dull, aching, or stabbing and may be aggravated by activities such as walking, climbing stairs, or prolonged sitting.  Range of motion in the lumbar spine may be limited due to pain.  Differential diagnosis includes lumbar disc herniation, piriformis syndrome, and facet joint arthritis.  Diagnostic imaging, such as X-ray, MRI, or CT scan, may be considered to rule out other pathologies.  Assessment points to sacroiliac joint dysfunction, consistent with sacroiliac joint syndrome.  The treatment plan includes conservative management with physical therapy focusing on core strengthening, stretching, and range of motion exercises.  NSAIDs or other pain medications may be prescribed for pain management.  Patient education regarding proper body mechanics and activity modification will be provided.  Referral to a pain specialist or orthopedist may be considered if symptoms persist or worsen despite conservative treatment.  ICD-10 code M54.6 Sacroiliac joint pain will be used for billing purposes.