(1)
Groningen, The Netherlands
Pelvic Pain
Complaint: the patient complains about pain at the pelvic level.
Assessment: if there is an anomaly at the level of one or both sacroiliac joints, then local pressure pain can be induced and Patrick test (Faber test) is positive (Fig. 4.1).
Fig. 4.1
Patrick test (Faber test): the child lies supine. The leg is placed in a figure of “four”. Next, the knee is pushed downwards. The test is positive if the patient indicates pain at the level of the ipsilateral sacroiliac joint
Differential diagnosis:
ankylosing spondylitis (Bechterew disease) septic sacroiliitis
tumor
Explanatory note: ankylosing spondylitis. This is a disease with inflammatory symptoms of the joints and in which the sacroiliac and intervertebral joints become involved before the other joints. The disease begins between the ages of 4 and 16. Patients may complain about the heels, the back, and pain at the level of the sacroiliac joints. Ankylosing spondylitis is characterized by the following symptoms:
Heel symptoms, low back symptoms or pain at the level of the sacroiliac joints that last longer than 3 months and does not clearly improve
stiffness of the thoracolumbar spine, especially in the mornings
thoracic excursions of less than 5 cm
iritis or iridocyclitis
elevated CRP and ESR
radiological erosions and narrowing of the sacroiliac joints
fast and good reaction to NSAID’s
in 90 % of cases there is an elevated HLA-B27
the rheumatoid factors are generally negative.
If one of the first four symptoms occurs in combination with a radiologically demonstrable bilateral sacroiliitis, this is sufficient for establishing a diagnosis of ankylosing spondylitis. About 0.1 % of the population older than 15 has ankylosing spondylitis. The disease is 45 times more common in boys than girls, and tends to become manifest at the end of puberty and early adulthood. The first symptoms are limited lateral mobility of the lumbar spine. The sacroiliac joints, which have already been affected at a very early stage, are painful on pressure. This disappears at a later stage once the joints are ankylosed.
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