HEALING THE CAPSULE:HEALING THE CAPSULE:THE SACROILIAC JOINT AND THE SACROILIAC JOINT AND

BEYONDBEYOND

Alfred H Grimes, MDAlfred H Grimes, MDPinnacle Pain MedicinePinnacle Pain Medicine

550 W Washington St #2550 W Washington St #2Carson City, NV 89703Carson City, NV 89703

775-841-7246775-841-7246

MY BACKGROUNDMY BACKGROUND

• BOARD CERTIFIED IN BOARD CERTIFIED IN ANESTHESIOLOGY-1984ANESTHESIOLOGY-1984

• PM&R RESIDENCY AT BAYLOR-BC IN 2001PM&R RESIDENCY AT BAYLOR-BC IN 2001

• PAIN FELLOWSHIP AT UCSF-SUBSPEC PAIN FELLOWSHIP AT UCSF-SUBSPEC CERT IN 2001CERT IN 2001

• AAOM-PROLO SINCE 2000AAOM-PROLO SINCE 2000

HOW WE DO PROLOHOW WE DO PROLOHistory-Physical ExamHistory-Physical Exam

Diagnostic then Therapeutic InjectionsDiagnostic then Therapeutic Injections

P2G +/- SMP2G +/- SMDILUTED WITH CARBOCAINE/MARCAINEDILUTED WITH CARBOCAINE/MARCAINE

FLUOROSCOPIC GUIDANCEFLUOROSCOPIC GUIDANCE

WHY FLUOROSCOPY?WHY FLUOROSCOPY?

• 1. INCREASED ACCURACY OF NEEDLE 1. INCREASED ACCURACY OF NEEDLE PLACEMENT. ESPECIALLY IN OBESE PATIENTS.PLACEMENT. ESPECIALLY IN OBESE PATIENTS.

• 2. ARTHROGRAMS SHOW INITIAL DAMAGE AS 2. ARTHROGRAMS SHOW INITIAL DAMAGE AS WELL AS SUBSEQUENT HEALING OF DAMAGED WELL AS SUBSEQUENT HEALING OF DAMAGED CAPSULES AND LIGAMENTS!CAPSULES AND LIGAMENTS!

• A PICTURE IS WORTH A THOUSAND WORDS!A PICTURE IS WORTH A THOUSAND WORDS!

• CAPSULAR TEARS CORRESPOND TO CAPSULAR TEARS CORRESPOND TO PAINFUL AREASPAINFUL AREAS

• ARTHROGRAMS CAN LET YOU KNOW ARTHROGRAMS CAN LET YOU KNOW WHEN TREATMENT IS COMPLETEWHEN TREATMENT IS COMPLETE

• THEY ARE HELPFUL IN CONVINCING THEY ARE HELPFUL IN CONVINCING PATIENTS OF THE NEED FOR FURTHER PATIENTS OF THE NEED FOR FURTHER TREATMENT DESPITE BEING PAIN FREETREATMENT DESPITE BEING PAIN FREE

WHY IS TREATING THE CAPSULE WHY IS TREATING THE CAPSULE IMPORTANT ?IMPORTANT ?• CAPSULE IS RICHLY INNERVATED, THEREFORE ANY CAPSULE IS RICHLY INNERVATED, THEREFORE ANY

STRETCHING OF CAPSULE OR INCOMPETENTENCY STRETCHING OF CAPSULE OR INCOMPETENTENCY WILL CAUSE PAIN.WILL CAUSE PAIN.

• CAPSULE SHOULD BE INTACT TO PREVENT CAPSULE SHOULD BE INTACT TO PREVENT EXTRAVASATION OF JOINT FLUIDEXTRAVASATION OF JOINT FLUID

• JOINT FLUID NOURISHES CARTILAGEJOINT FLUID NOURISHES CARTILAGE• LACK OF JOINT FLUID LEADS TO IMPINGEMENT, PAIN, LACK OF JOINT FLUID LEADS TO IMPINGEMENT, PAIN,

AND DEATH OF CARTILAGE.AND DEATH OF CARTILAGE.• CAPSULE INTEGRITY A MUST.CAPSULE INTEGRITY A MUST.• ONLY WITH ARTHROGRAMS CAN BE SURE HEALING IS ONLY WITH ARTHROGRAMS CAN BE SURE HEALING IS

COMPLETE.COMPLETE.

Gabrielle FGabrielle F

• 44 y/o F44 y/o F

• Complaint was abdominal (Low Pelvic) Complaint was abdominal (Low Pelvic) painpain

• GI/Surgical w/u nondiagnosticGI/Surgical w/u nondiagnostic

• Diagnostic SIJ injections eliminated pain Diagnostic SIJ injections eliminated pain for 24 hours.for 24 hours.

ROBERT GROBERT G

• 42 y/o male injured shoulder while 42 y/o male injured shoulder while working on automobileworking on automobile

• Presented with classic impingement signsPresented with classic impingement signs

REINJURYREINJURY

JAMES NJAMES N

• 63 y/o male injured shoulder while skiing, 63 y/o male injured shoulder while skiing, weight liftingweight lifting

• Classic impingementClassic impingement

GREGORY RGREGORY R

• 45 y/o male with injury secondary to 45 y/o male with injury secondary to rugby, skiingrugby, skiing

• Classic impingementClassic impingement

L ShoulderL Shoulder

R ShoulderR Shoulder

Shannon RShannon R

• 33 y/o triathelte with L ankle pain, h/o 33 y/o triathelte with L ankle pain, h/o twisting ankle multiple timestwisting ankle multiple times

• Failed cortisone, refused ankle fusionFailed cortisone, refused ankle fusion

Patrick PPatrick P

• 50 y/o M50 y/o M

• R toe pain, s/p fusionR toe pain, s/p fusion

R HIP PROLOR HIP PROLO

• 76 Y/O Female with R hip pain s/p R SIJ 76 Y/O Female with R hip pain s/p R SIJ proloprolo

QUESTIONS?QUESTIONS?